Susan Usztics (“Usztics”) was employed as a program manager for MSX International, Inc. Through her employment, she held a short-term disability benefits policy which was administered by Unum Life Insurance Company of America (“Unum”). Her last day of work was February 4, 2014, following which she applied for short-term disability benefits because of fibromyalgia, anxiety, and depression. Under the benefits policy, “disability” was defined as the following:
“You are disabled when Unum determines that: you are limited from performing the material and substantial duties of your regular occupation due to sickness or injury, and you have a 20% or more loss in weekly earnings due to the same sickness or injury.
. . .
Material and substantial duties means duties that: are normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified.”
According to Usztics’ job description, her duties require that she “[p]rovide[es] PM support for global rollout of PeopleSoft General Ledger, Accounts Receivables, and Billing.” Further, a Unum employee also requested information from MSX International, which reported that “she believes [the PM position] is a sedentary office job” and that accommodations “may be” available.
Usztics’ disability application explained that she first began to experience fibromyalgia in 1997, citing “leg arm pain[,] cramping[, and] overall pain.” However, she did not begin specialized treatment for this until 2006, beginning with a rheumatologist, Dr. Luis E. Torregrosa. She reported four visits with Dr. Torregrosa from July 1, 2013, to February 26, 2014.
On her first visit, she stated that she “began experiencing an acute exacerbation of her fibromyalgia with worsening pain[.]” This included her “trunk and all four extremities.” Upon examination by Dr. Torregrosa, Usztics indicated “[t]ender points were noted in areas including but not limited to the cervical spine, lumbosacral spine, chest wall, medical aspect of both knees and lateral epicondycles.” As a result of this, Dr. Torregrosa suggested that she cease work for several days.
The second visit, on October 21, 2013, showed a report of feeling “worse overall . . . having some problems sleeping, has stopped exercising because of worsening of her pain and her pain is present on a chronic widespread basis involving the trunk and all four extremities.” Dr. Torregrosa opined that Usztics was suffering from “dual comorbidities of depression and fibromyalgia syndrome.” On the third visit, Dr. Torregrosa explained that “[o]verall issues remain[ed] essentially unchanged but she [was] tolerating her medications well and might be doing somewhat better from a mood perspective.”
Her last visit to Dr. Torregrosa was in February of 2014. At that time, Dr. Terrogrosa said that “Tender points were noted in areas including, but not limited to the cervical spine, lumbosacral spine, chest wall, medical aspects of knees and lateral epicondyles.” He further opined that the “severity of her symptoms” required that she not work for a “couple of months.” Dr. Torregrosa subsequently contributed to Usztics’ disability benefits application by explaining that ‘[t]his patient is completely disabled at this time and is not able to work in any capacity” as of the February 2014 date. He cited her medical treatment plan as including “multiple meds: Paxil 30 mg/day, Pregabalin . . . Amitriptiline, Sonma, [and] Norco[.]” He opined that Usztics could walk, twist or bend, stand, and sit, reach above her shoulders, and “[o]ccasionally lift up to ten pounds,” but that she could “[n]ever lift more than eleven pounds or climb. Lastly, Dr. Torregrosa said that he was “not able to provide . . . a definite date of return to work” because of her “extreme symptoms.”
On February 21, 2014, Unum interviewed Dr. Torregrosa who reported that “she feels [she] has a lot of problems with extremities, charlie horses, shooting pain in her legs . . . pains shoot anywhere from fingertips up to her shoulders . . . sometimes she is in total pain.” Later, Unum chose to deny Usztics’ claim because “[t]here is no information in your medical to show a change or worsening in your condition.” More specifically, that “[t]he medical notes from June 19, 2013 through February 05, 2014 [did] not support a change in severity, pattern, or medical necessity to limit your activity levels beginning February 05, 2014.” Unum also explained that “there [were] no specific restrictions and/or limitations to help explain which of your occupational duties you cannot do.”
At this point, Usztics asked for a reconsideration of the decision and subsequently appealed it. She supplied a new letter from Dr. Torregrosa, and her entire file was then referred to a Senior Clinical Consultant for review. The consultant stated that Dr. Torregrosa’s observations “seem to be stereotyped and nearly identical in each office visit” and that Usztics’ activities were “inconsistent” with a determination of “completely disabled” and “unable to work in any capacity.” After this review, Unum affirmed its denial. Usztics then filed the instant suit.
Usztics claimed that Unum acted in an arbitrary and capricious manner by denying her claim. However, the Court ruled that she was unable to show any evidence that she was not disabled under the definition of the plan. It explained that she did not indicate how she could not perform her duties or that her severity had increased to the level where she was unable to work.
Usztics additionally argued that Unum should have used an independent medical examination of her instead of a file review, and that a physician should have done the file review instead of a nurse. However, here, the Court felt that the file review that was done considered all available medical evidence as required by the plan. Lastly, the Court cited case law that explained that there was nothing wrong with having a nurse review a case file, as long as she was fully capable of doing so. In this case, it agreed that the nurse was capable of reaching the conclusions that she did. Therefore, for the reasons above, the Court ruled in favor of Unum and against Usztics, dismissing the suit.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: