iKhan v. Provident Life & Accident Insurance Company, 386 F. Supp. 3d 251 (W.D.N.Y. 2019)
Dr. Khan was a hospital-employed neurologist for many years before he stopped work. He had progressively worsening and debilitating symptoms including fatigue and pain, variously and inconsistently diagnosed over the years, but ultimately confirmed to be granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis, a complex and obscure condition that can cause fatigue, joint pain, and many other symptoms. Under the policy applicable to his claim, Dr. Khan was entitled to benefits if he was unable to perform the material and substantial duties of his own occupation for 12 months and thereafter if he was unable to perform the material and substantial duties of any occupation. Dr. Khan’s primary care physician and the many specialists he consulted agreed he was disabled by pain and fatigue. The Social Security Administration granted Dr. Khan’s application for SSDI benefits. Provident Life & Accident Insurance Company (part of Unum) denied Dr. Khan’s claim and denied his internal appeal. Employees of Unum Group, the parent company of both Unum Life Insurance Company of America and Provident Life & Accident Insurance Company, made the decisions to deny Dr. Khan’s claim and his internal appeal of that denial. We sued. The district court judge agreed with our arguments and disagreed with Unum/Provident’s decision and ordered payment not only of Dr. Khan’s own occupation benefits but also of any occupation benefits.
The judge reasoned that it was apparent that Unum/ Provident/s opinions and those of its reviewing doctors stood or fell on the credibility of Dr. Khan’s subjective complaints. The judge found that Dr. Khan had proved by a preponderance of the evidence – the unanimous opinions of the physicians who examined him – that he suffers from medical determinable impairments that could reasonably be expected to produce the pain and fatigue alleged. The judge noted that the SSA found that the severity of Dr. Khan’s symptoms were wholly substantiated by his own statements and the medical records from his doctors and that none of the physicians who examined him ever suggested he was malingering or engaging in symptom magnification. The judge also concluded that Unum/Provident and its medical reviewers attacks on Dr. Khan’s credibility were without merit: Dr. Khan consistently and routinely complained of fatigue and joint pain to all of his physicians. Unum/Provident’s doctors argued that Dr. Khan’s treatment was not sufficiently aggressive, arguing that Dr. Khan’s low dosage of prednisone undercut his claims of symptom severity. But, Dr. Khan took that low dosage because higher daily doses led to severe side effects. Unum/Provident’s doctors reasoned that Dr. Khan’s date of disability was within two weeks of his termination from his position; but the reason for his termination was that he was not meeting expectations or seeing enough patients, as Dr. Khan told his treating doctors and asserted in his appeal. Unum/Provident and its doctors argued that because Dr. Khan could read, use a computer, and do occasional household chores and grocery shop he was not disabled. The judge disagreed, reasoning, “there is, quite obviously, nothing inherent in these activities that proves Plaintiff has the ability to perform the exertional and cognitive demands of a hospital neurologist, much less to do so eight hours a day, five days a week. . .”
Unum/Provident argued that Dr. Khan did not meet his burden of proving his disability under the terms of the policy and it properly declined to credit his doctors because their opinions merely recited Dr. Khan’s subjective complaints of pain and fatigue and there were no tests to confirm, objectively the extent of the limitations caused by those complaints. The judge rejected that argument, explaining that nothing in the policy required objective proof and that the subjective element of pain is an important factor to be considered in determining disability. Therefore, the judge concluded Unum/Provident and its doctors acted improperly by conditioning coverage on proof of objective indicators of Dr. Khan’s complaints of fatigue and pain when no such proof is medically possible. The judge held that Unum/Provident attempted to impose a requirement of objective proof that is not contained in the policy and that Unum/Provident and its medical reviewers arbitrarily ignored Dr. Khan’s subjective complaints of fatigue and pain.
As done with Dr. Khan, Unum and Provident often improperly discount subjective symptoms, such as pain and fatigue and often demand objective evidence to prove disability when no such requirement is in the policy.
If your claim for disability benefits is denied or terminated by Unum Life Insurance Company of America or its sister corporation, Provident Life & Accident Insurance Company, the ERISA Law Center can help you get those benefits.