Scott v. UNUM Life Insurance Co. of America

80 So. 3d 740, 2011 WL 7801556, 2011 La. App. LEXIS 1576
CourtLouisiana Court of Appeal
DecidedDecember 19, 2011
DocketNo. 46,652-CA
StatusPublished
Cited by1 cases

This text of 80 So. 3d 740 (Scott v. UNUM Life Insurance Co. of America) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Scott v. UNUM Life Insurance Co. of America, 80 So. 3d 740, 2011 WL 7801556, 2011 La. App. LEXIS 1576 (La. Ct. App. 2011).

Opinion

DREW, J.

|, Unum Life Insurance Company appeals a judgment ordering it to pay continued disability benefits, attorney fees, and a penalty to Gary Scott.

We amend the judgment to reduce the penalty and attorney fees awarded, and as amended, we affirm the judgment.

FACTS

Gary Scott, who was born in 1954, was employed as a master plumber and pipefit-ter at the University of Louisiana at Monroe (“ULM”), where he worked for 16 years. Scott began paying for disability insurance while working at ULM.

The disability insurance was originally offered through another insurer before Unum took over the program. The policy read:

“Disability” and “disabled” mean that because of injury or sickness:
1. the insured cannot perform each of the material duties of his regular occupation; and
2. after benefits have been paid for 24 months, the insured cannot perform each of the material duties of any gainful occupation for which he is rea- ' sonably fitted by training, education or experience.

The policy also stated that the benefit would be paid for the period of disability if the insured gave to Unum proof of continued disability and “regular attendance of a physician.” Proof of these facts must be given, at the policyholder’s expense, when Unum asked for it.

Scott recalled twice injuring his back at work. The first time occurred in 2000 when he picked up a concrete lid for a fountain. The second time occurred in 2004 when he picked up an ice machine. Dr. David Hebert began treating Scott in 2003 for severe lower back pain and other physical | ¡¡ailments. As early as December of 2004, Dr. Hebert suspected that Scott was clinically depressed.

Scott stopped working on September 1, 2006. After treating Scott on October 30, 2006, Dr. Hebert thought he was basically disabled, mostly because of his depression, although he also felt degenerative joint disease of the lumbar spine and chronic [743]*743low back pain contributed to Scott’s inability to work his job at ULM.

Scott applied for disability benefits in early December of 2006. On December 18, 2006, Michael Marley, the Unum disability benefits specialist assigned to Scott’s claim, sent a claim initiation letter to Scott. Marley wrote that in order to determine if Scott met the policy definition of disability, Unum would need additional information about his restrictions and limitations and the requirements of his occupation.

Marley called Scott on December 26, 2006, to get additional information to evaluate his claim. Scott told Marley that he was not working because of back problems and depression, and that he was being treated by Dr. Hebert. Scott also discussed his medications. Marley said he went over the definition of disability with Scott at that time.

On January 5, 2007, Dr. Hebert completed an “Attending Physician’s Statement for Disability Benefits.” The diagnoses made by Dr. Hebert were degenerative joint disease of the lumbar spine and major depressive disorder without psychosis. Dr. Hebert gave September 2006 to February 2007 as the approximate duration of disability.

Is Amy Herrick, a clinical consultant for Unum, called Dr. Hebert on January 11, 2007. Dr. Hebert told Herrick that he felt duped by Scott because he thought that Scott would return to work; instead, Scott wanted to remain on disability indefinitely and had no intention of returning to work. Dr. Hebert also told Herrick that Scott needed to get an MRI and to see an orthopedic specialist and a psychologist, which Scott was refusing to do. Dr. Hebert added that he had thought Scott would need only one to two months of disability when he signed the disability papers for Scott. According to Dr. Hebert, Scott’s depression was a far greater issue than his back condition, and he felt that Scott needed to seek further treatment instead of just taking medications.

Dr. Peter Kouros, a medical consultant for Unum, reviewed Scott’s file and felt that additional information was needed to accurately assess any possible impairment. Dr. Kouros recommended a psychiatric independent medical examination (“IME”) and a functional capacity evaluation (“FCE”) to better delineate Scott’s present functional capacity.

On January 20, 2007, Scott received a letter from Marley stating that Unum had approved his request for benefits. The letter reproduced the policy’s definition of disability. Scott was told that in order to qualify for ongoing benefits, he must continue to meet the definition of disability, and that Unum would periodically request medical evidence and vocational information to support the continuation of benefits. Marley also wrote that because the extent of Scott’s disability was unclear, Unum wanted him to undergo a FCE and a psychiatric IME in order to fully evaluate his claim. pMarley added that because Scott had not sought treatment from an orthopedist or a psychiatrist as recommended by Dr. Hebert, his claim was being approved under a reservation of rights.1 Finally, Marley wrote that in order for Scott to be eligible for benefits beyond December 1, 2008, he needed to be disabled from any gainful occupation as a result of his physical condition.

[744]*744Unum began paying benefits of $978.29 per month under the policy effective December 2, 2006.2 The first check covered the period of disability from December 2, 2006, through January 1, 2007.

Scott’s FCE was performed by Jay Manning on February 13, 2007. Manning concluded that Scott was able to work at the light physical demand level.

Dr. George Seiden performed the psychiatric IME of Scott on behalf of Unum. Dr. Seiden’s impression was that Scott had an adjustment disorder with depressed mood. Dr. Seiden believed that Scott was having a complicated grief reaction to his father’s death. Dr. Seiden felt that Scott’s depression was readily treatable and that he was never completely disabled by his depressive disorder. He did not think that Scott had received appropriate care for his psychiatric condition, although he recognized that treatment would be difficult because of Scott’s lack of motivation to improve.

| ¿On March 20, 2007, Dr. Kouros examined Scott’s medical records and concluded that Scott’s occupational demands were in excess of his reasonable functional capacity as demonstrated by the FCE. Dr. Kouros noted that Scott’s evaluation was limited because of Scott’s refusal to complete studies or referrals.

On October 23, 2007, Marley wrote to Scott that based upon the results of the FCE, Scott was disabled from his regular occupation as a plumber/pipefitter because of his back condition. Marley also wrote that the psychiatric IME did not support psychiatric impairment that prevented Scott from performing his occupation, and thus, it did not appear that he was disabled due to depression.

In March of 2008, Marley wrote to Scott to inform him that Unum was beginning to review his eligibility for benefits beyond the initial 24-month period. In November of 2008, Robin Giese performed a vocational assessment in which he identified security guard and gate guard as vocational options for Scott. Giese thought those positions were consistent with Scott’s prior work history, skills, education/training, demonstrated general educational development levels, and restrictions and limitations.

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80 So. 3d 740, 2011 WL 7801556, 2011 La. App. LEXIS 1576, Counsel Stack Legal Research, https://law.counselstack.com/opinion/scott-v-unum-life-insurance-co-of-america-lactapp-2011.