1st Cir. / ERISAshoke2013
Insurer Requirement of Evidence of Functional Limitations Reasonable in Determining Applicability of Self-Reported Symptoms Limitation
The United States Court of Appeals for the First Circuit, applying federal law, affirmed the district court’s grant of summary judgment to the insurer Unum Life Insurance Company of America (“Unum”), finding that its application of a plan’s self-reported symptoms (“SRS”) benefit limitation when faced with no objective evidence of functional limitations was reasonable. The First Circuit’s decision endorsing Unum’s application of the SRS limitation stands in contrast to the Seventh Circuit’s determination that a nearly identical SRS limitation provision is only reasonably applied to disabling illnesses or injuries that are diagnosed primarily based on self-reported symptoms rather than to all illness or injuries for which the disabling symptoms are self-reported.
In the instant case, the plaintiff is a professor at Rollins College and a participant in her employer’s long-term disability plan, which is insured and administered by Unum and governed by the Employee Retirement Income Security Act (“ERISA”). The plaintiff was initially granted disability benefits under the plan in 2011 upon diagnoses of chronic fatigue syndrome, fibromyalgia, and associated symptoms including pain and fatigue based on her self-reported symptoms and objective medical evidence. The SRS limitation within the plan provides for a maximum benefit period of 24 months for “disabilities due to mental illness and disabilities based on self-reported symptoms.” In 2015, after about 43 months of paying benefits to the plaintiff, Unum terminated long-term disability benefits pursuant to the SRS limitation.
After an unsuccessful administrative appeal, the plaintiff filed an ERISA action, seeking recovery and reinstatement of her benefits. Specifically, the plaintiff challenged Unum’s requirement that she provide objective evidence of her functional limitations, defined as a restriction or lack of ability in performing an action as a result of the disability. Because the plan affords the insurer discretion in determining eligibility for benefits, the First Circuit reviewed Unum’s decision to terminate benefits under a deferential arbitrary and capricious standard.
Applying this standard, the First Circuit found that Unum’s decision to terminate the plaintiff’s benefits was indeed reasonable and supported by substantial evidence. Specifically at issue was Unum’s requirement of objective proof of the plaintiff’s functional limitations. The First Circuit distinguished between an insurer’s requirement of objective evidence in support of diagnoses like fibromyalgia and chronic fatigue syndrome which are not subject to objective verification (which the First Circuit has previously held to be unreasonable) and a requirement of objective evidence in support of functional limitations caused by the illness (which the First Circuit has previously found to be reasonable). The First Circuit labeled this difference the “diagnosis-disabling symptom distinction.”
The First Circuit found that Unum reasonably applied the latter requirement. Unum paid benefits to the plaintiff for the 24 months stipulated by the SRS limitation, and following the expiration of that period, properly sought objective proof that her diagnosed diseases affected her ability to work. Furthermore, the First Circuit reviewed the plaintiff’s medical history and the insurer’s multiple reviews of the plaintiff’s claims and determined that Unum’s determination to terminate disability benefits was supported by substantial evidence. In particular, the First Circuit did not dispute Unum’s rejection of the plaintiff’s sole submission of objective evidence, given that the submitted result from a Cardiopulmonary Exercise Test was subject to contradictory conclusions by different doctors.
Ultimately, the First Circuit affirmed its own precedent’s “diagnoses-disabling symptom distinction,” even though it resulted in a different interpretation of the SRS limitation than that reached by the Seventh Circuit. The Seventh Circuit, in Weitzenkamp v. Unum Life Ins. Co. of Am., 661 F.3d 323 (7th Cir. 2011), applied the SRS limitation only to disabling illnesses or injuries that are diagnosed primarily based on self-reported symptoms. Such an interpretation would yield the SRS limitation inapplicable to the plaintiff in the instant case, as her diagnoses were based on objective medical evidence. The First Circuit, however, rejected that interpretation on the principle that functional limitations better lend themselves to objective analysis. As such, the First Circuit found that Unum’s requirement that the plaintiff provide objective evidence of her functional limitations was indeed reasonable, and because the plaintiff was unable to show any proof, it affirmed the district court’s grant of summary judgment in favor of Unum. Ovist v. Unum Life Ins. Co. of Am., 20-1464, 2021 WL 4304547 (1st Cir. Sept. 22, 2021).