Williams v. UNUM Life Insurance Co. of America, 2003 WL 1801036 Virginia, Alexandria Division

District Court Judge Brinkema

Plaintiff stopped working because he suffered from knee pain.  Nine months after leaving the job, he was diagnosed with fibromyalgia.  He brought this ERISA action against the Defendant as result of Defendant’s denial of short-term and long-term benefits under a employee welfare benefit plan.  This case comes before the court on Plaintiff’s motion for judgment on the administrative record and Defendant’s motion for summary judgment.

Plaintiff’s short term disability claim was denied by the Defendant for several reasons.  His initial claim was denied on the basis of no disability documented by medical evidence, because at the time he simply complained of soreness and pain in hands and feet.  The Plaintiff was later diagnosed with fibromyalgia (nine months after he stopped working) and he asked to be reconsidered for short term disability.  The Defendant again denied benefits, noting that the plan required him to be disabled at the time he stopped working, and that the new evidence therefore would not be considered.

Defendant asserted that summary judgment should be granted because Plaintiff’s claim for benefits are payable, if at all, by his employer.  Summary judgment on this basis was denied.  Although the employer was listed as the plan administrator, all evidence in the administrative record contradicted this conclusion.  Specifically, the plan documents state that the Defendant will make all determinations of eligibility of coverage, disability, and eligibility for benefits, and adjudicate any appeals of denied claims.  The court therefore concluded that the employer delegated the responsibility of administrating the program to the Defendant, and that the Defendant was the proper party in the suit.

In considering the motions, the court applied the abuse of discretion standard to the denial of the benefits, noting that there were no evidence of bias or self-dealing to apply a heightened standard. In reviewing the administrative record, there was medical evidence from Dr. Frederick Austin stating that although the Plaintiff complained of pain in the knees and legs, the pain had improved and he was able to walk for long hours during the day and his neurological exam was normal.  Dr. James Alloway, another treating physician, noted in his records that he couldn’t find any true active inflammatory synovitis in this knees and that the Plaintiff was primarily suffering from mild arthritis.  Dr. Barrie Hurwitz, an assistant professor at Duke University Medical Center, reported that the Plaintiff neurologically appeared normal.  Plaintiff provided no evidence that his treating physicians had recommended that he stop working.

Based on the foregoing, the court denied Plaintiff’s motion for judgment on the administrative record, and granted Defendant’s motion for summary judgment.  The Defendant’s conclusion that the medical evidence did not support a finding of disability was reasonable and not an abuse of discretion.  The court also failed to accept Plaintiff’s argument that objective evidence is not a requirement in determining disability because it was not specifically required by the plan.  It accepted Defendant’s interpretation that there must be objective evidence, and that interpreting such a requirement was not an abuse of discretion.