Erisa and Disability Benefits Law Blog

James O'Rear, a 63 year-old former employee of Lockheed Martin, submitted a claim for long-term disability benefits under his employer's ERISA plan.  He had physical problems due to a spinal-related condition.  The insurer paid disability benefits for approximately two years, during the "own occ" period, but then determined that O'Rear did not qualify under the “any occ” definition.  After exhausting the internal appeals process, O’Rear sued the insurer.  (The case caption identifies the defendant as "Unum Life Insurance Company of America," but the opinion refers to the defendant as "Paul Revere Life Insurance Company.")  The insurer moved for summary judgment. 

The court discussed the history of the claim: O”Rear had back surgery shortly after his “own occ” period began.  His treating doctor submitted three “Attending Physician Statements” stating that O’Rear could not work.  After the third Statement, the insurer began a vocation evaluation and determined that O’Rear could perform one of three occupations given his education, training, experience, and physical abilities.  In his appeal, O’Rear submitted a fourth statement from his doctor stating that O’Rear had constant hip pain and back pain and could not work.  In an “Estimated Functional Abilities Form,” the doctor also reported that O’Rear had increasingly worsening pain and that his condition was unlikely to get better.   

The insurer obtained an in-house medical review of the materials.  The reviewer found that no diagnostic tests or office notes existed to support the treating doctor’s conclusions.  The reviewer stated that the Estimated Functional Abilities Form showed “physical functional ability within the expected range for his [O'Rear's] clinical history.”  As a result, the insurer determined that there was inadequate evidence to reverse its decision.

Based on the contents of the claims file, the court summarily concluded that the insurer’s termination of benefits was not arbitrary and capricious.  In a footnote, the court stated that “the only evidence the court may consider are the contents of the administrative record.  [Citation omitted.]  O'Rear failed to reply to Paul Revere's Motion for Summary Judgment and thereby identify any favorable evidence contained in the record. In addition, despite several requests by Paul Revere to supply additional diagnostic and treatment information, O'Rear took no action.” 

The cite is O'Rear v. Unum Life Ins. Co. of America, 2006 WL 2457096 (W.D. La. Aug. 21, 2006).