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Prokhorova v. Unum Life Insurance Company of America

United States District Court, D. Massachusetts

April 23, 2018




         This is an action brought by plaintiff Natalya Prohkorova (“Plaintiff”) pursuant to the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1001 et seq., to recover long-term disability (“LTD”) benefits allegedly wrongfully discontinued by the defendant, Unum Life Insurance Company of America (“Unum”). Plaintiff has moved to supplement the administrative record (“A.R.”) by adding (1) six portions of Unum's Benefits Center Claims Manual (“Claims Manual”); (2) documents concerning Unum's quality compliance criteria (which Unum has not produced); and (3) vocational resource material. Unum opposes the motion. For the reasons that follow, Plaintiff's Motion to Supplement the Record is GRANTED in part and DENIED in part.

         I. The Claim

         At the onset of Plaintiff's disability, she was employed as a pediatrician.[1] She filed an LTD claim, an individual disability claim, and a life waiver of premium claim with a January 3, 2007 date for the onset of disability. She began receiving disability benefits based on her inability to perform the material and substantial functions of her job as a pediatrician based on a diagnosis of herniated nucleus polposus of the thoracic spine and thoracic radiculopathy (Dkt. No. 18-1 at 3). In July 2013, Unum obtained updated medical information from Plaintiff. According to the appeal decision, a December 4, 2015 thoracic MRI showed no finding of stenosis or nerve root compression that would be consistent with thoracic radiculopathy or local thoracic pain. Compared with a 2008 MRI, the size of the thoracic disk herniation had decreased to the point that, in a December 14, 2014 study, there was no longer any disc herniation seen (id. at 3-4). Unum referred Plaintiff for a psychiatric IME (independent medical examination) to assess the possibility that Plaintiff's complaints of chronic pain were psychiatric in nature. The IME did not result in the diagnosis of any psychiatric condition or a recommendation for any psychiatric or behavioral health care treatment (id. at 4). Unum concluded that Plaintiff was no longer disabled because test results did not support a disabling back condition, there was no psychiatric diagnosis, and her complaints of chronic disabling pain were inconsistent with objective test results (id.).

         II. Legal Framework

         The parties agree on the standard of review in this denial of benefits case. They agree that the LTD plan under which Plaintiff claims to be entitled to benefits “reserves discretion to the administrator [, Unum, so that] judicial review of the denial [of benefits] is limited to determining whether the administrator acted arbitrarily and capriciously.” Liston v. Unum Corp. Officer Severance Plan, 330 F.3d 19, 22 (1st Cir. 2003) (citing Leahy v. Raytheon Co., 315 F.3d 11, 15 (1st Cir. 2002); Doe v. Travelers Ins. Co., 167 F.3d 53, 56-57 (1st Cir. 1999)). They further agree that Unum “both determines whether an employee is eligible for benefits under [the LTD plan] and pays those benefits out of its own pocket, [and that] ‘this dual role creates a conflict of interest.'” Wilson v. Pharmerica Corp. Long Term Disability Plan, 102 F.Supp.3d 373, 374 (D. Mass. 2015) (quoting Metro Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008)).[2] In Glenn, the United States Supreme Court held that when, as here, such a structural conflict exists, judges reviewing denial of benefits decisions “should weigh a conflict as they would any other pertinent factor; that is, when the relevant considerations are in equipoise, any one factor, including a structural conflict, may act as a tiebreaker.” Denmark v. Liberty Assurance Co. of Boston, 566 F.3d 1, 8 (1st Cir. 2015) (citing Glenn, 554 U.S. at 116-17).

         “ERISA benefit-denial cases typically are adjudicated on the record compiled before the plan administrator.” Id. at 10. In Denmark, the First Circuit stated that “Glenn fairly can be read as contemplating some discovery on the issue of whether a structural conflict has morphed into an actual conflict. See, e.g. Glenn, [554 U.S. at 117]. . . . But any such discovery must be allowed sparingly and, if allowed at all, must be narrowly tailored so as to leave the substantive record essentially undisturbed.” Id. After a review of the documents at issue and Plaintiff's arguments for supplementation, the court concludes that the documents with which Plaintiff seeks to supplement the A.R. are not related to Unum's structural conflict. Plaintiff has not identified any “gap in the administrative record” related to Unum's “procedures used to prevent or mitigate the effect of structural conflicts, ” id., that she seeks to address by supplementing the A.R.

         Instead, for the most part, Plaintiff seeks to supplement the A.R. with internal documents from Unum, such as portions of its Claims Manual, which Plaintiff claims are analogous to an administrative agency's guidelines and regulations as a basis for challenging aspects of Unum's process in evaluating her claim (Dkt. No. 17 at 4). “The administrator's obligation to avoid arbitrary and capricious behavior extends to procedure as well as substance.” Liston, 330 F.3d at 25 n.5 (citing Perlman v. Swiss Bank Corp. Comprehensive Disability Prot. Plan, 195 F.3d 975, 981 (7th Cir. 1999)). In Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113, 122 (1st Cir. 2004), the First Circuit held that the plan administrator's internal documents “interpreting the language of the [p]lan and providing the standard for evaluation of the facts presented” should be considered as part of the administrative record in the benefits denial case before the court where those documents were relevant to the interpretation of the plan terms on the basis of which the plan administrator had denied benefits. See Id. at 124, 126. Subsequently, the First Circuit addressed a claimant's contention that the district court should have provided the claimant with discovery to determine whether the claims staff and medical reviewers followed procedure and were properly educated and trained. The First Circuit affirmed the district court's denial of the requested discovery on the ground that “[t]here was no serious claim of bias or procedural misconduct toward [the claimant] . . . and that ‘at least some very good reason [wa]s needed to overcome the strong presumption that the record on review is limited to the record before the administrator.'” Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 520 (1st Cir. 2005) (quoting Liston, 330 F.3d at 23). “The weight and admissibility of internal documents, whether those documents are offered in support of the interpretation of the plan administrator or that of the claimant, will vary with the facts of each case.” Glista, 378 F.3d at 123. The question after Glista and Orndorf is whether, with respect to the specific materials Plaintiff has identified, she has shown some very good reason in the context of this case to overcome the strong presumption against supplementing the record on which the plan administrator's decision was based.

         III. Discussion

         1. Unum Claims Manual[3]

         When there is an adverse benefits determination with respect to a claim for disability benefits, a plan administrator is required to provide the claimant with relevant documents, defined as documents, records, or other information that were “relied upon in making the benefit determination;” were “submitted, considered, or generated in the course of making the benefit determination without regard to whether such document, record, or other information was relied upon in making the benefit determination;” “[d]emonstrate[] compliance with the administrative processes and safeguards required . . . in making the benefit determination;” or are “statement[s] of policy or guidance with respect to the plan concerning the denied . . . benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.” 29 C.F.R. § 2560.503-1(m)(8)(i)-(iv) (2017).

         Although it is not clear that the Unum Claims Manual constitutes a “relevant document” within this definition in all cases, at the hearing, Unum's attorney represented that Unum routinely provides its Claims Manual to claimants' counsel. Plaintiff argues that selected portions of the Claims Manual, identified below, should be added to the A.R. (Dkt. No. 26 at 1).

         The court addresses each proposed addition in turn.

         A. Functional Capacity and Occupational Demands; Occupational ...

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