Opinion ID: 2543
Heading Depth: 3
Heading Rank: 1

Heading: The First Benefit Denial

Text: First Unum's long-term disability policy defines disability and disabled as follows: Disability and disabled mean that because of injury or sickness: 1. the insured cannot perform each of the material duties of his regular occupation; or 2. the insured, while unable to perform all of the material duties of his regular occupation on a full time basis, is: a. performing at least one of the material duties of his regular occupation or another occupation on a part-time or full-time basis; and b. earning currently at least 20% less per month than his indexed pre-disability earnings due to that same injury or sickness. When McCauley first applied for long term disability benefits, First Unum requested additional information from his treating physician about his ability to perform his job duties in order to ascertain whether he qualified as disabled under the policy's definition. In response, McCauley's physician wrote that: (1) [McCauley] is restricted to heavy lifting and extreme physical exertion. He also has limitations on increased workload secondary to fatigue syndrome, occasional nausea and pain in the right upper abdominal quadrant secondary to hepatic resection. (2) [McCauley] is limited to extreme workload and increased hours due to fatigue, nausea and intermittent pain. [1] The medical records before the administrator also showed that McCauley was chronically stable and that there was no evidence of active cancer. Upon reviewing this information, a nurse employed by First Unum determined that the medical record does not support total impairment. First Unum therefore concluded that McCauley was not disabled because his regular occupation as a tax attorney was sedentary. First Unum communicated this conclusion to McCauley in a letter stating: [T]he medical information does not support an impairment of such severity that would preclude your ability to perform your occupation. [Your physician] restricted you from heavy lifting and extreme physical exertion. He also limited increased workload and increased hours. These restrictions and limitations would not prevent you from performing the material duties of your sedentary occupation. Like the district court, we conclude that First Unum's initial denial is supported by the correspondence from McCauley's physician and other medical information in the administrative record. The record before First Unum at the time of the denial indicated that McCauley's cancer had been treated successfully and that his restrictions were limited to extreme workload, increased hours, heavy lifting, and extreme physical exertion. First Unum's denial under those circumstances was therefore not arbitrary and capricious. First Unum's response also invited McCauley to send new, additional information to support [his] request for disability benefits. First Unum stated that a request for review of its decision should be accompanied by his comments and views of the issues, as well as any documentation [he] wish[es] First UNUM to consider. First Unum thus allowed McCauley to appeal its decision directly to First Unum and permitted him to submit additional information in support of his appeal. Accordingly, McCauley requested a review of the benefits denial, which was processed internally by a First Unum claims appeal specialist in coordination with the First Unum nurse who originally recommended that McCauley's claim be denied.