In Bruton v. American United Life Insurance Corporation, 2020 WL 398539 (6th Cir. Jan. 2020) Plaintiff was employed starting in July 2006 as a “Technology Development Manager” with a management firm in Ohio. His employer contracted with Defendant American United Life Insurance Corporation (American United) to provide short-term (STD) and long-term (LTD) disability benefits to its employees.

American United hired a claims administrator, Disability RMS (DRMS), to review claims and determine whether an applicant qualifies for benefits under the employer’s disability benefits plan (the Plan). DRMS determined that Bruton qualified for STD, but ultimately denied his LTD application. He appealed that determination, and DRMS denied the appeal. He then filed an ERISA lawsuit. The district court also determined that Plaintiff was not eligible for LTD benefits under the Plan. Plaintiff appealed to the 6th Circuit.

Procedural History & District Court Decision

Plaintiff filed a complaint in district court, seeking to appeal DRMS’s determination under ERISA. After a de novo review of the record, the district court concluded that Plaintiff had failed to prove that he was “totally disabled” under the terms of the Plan, including that he be in “Regular Attendance of a Physician.” The district court determined that Plaintiff failed to meet this requirement of the Plan because: (1) he failed to follow standard medical practice to manage his pain; (2) he failed to undergo an updated MRI as recommended; (3) he failed to pursue aquatic therapy as recommended; (4) he failed to follow through with a referral to a physical medicine and rehabilitation specialist; and (5) he had expressed worsening pain complaints as he was being prescribed greater and greater doses of opioids.

The district court also concluded that Plaintiff failed to establish that he could not perform the “Material and Substantial Duties of his Regular Occupation” because there was a “lack of objective medical and other evidence to support his physician’s opinion that Plaintiff was incapable of performing his regular sedentary employment. On appeal the 6th Circuit overturned the District Court’s decision and awarded Plaintiff benefits through the full 24-month “own occupation” period.

Plaintiff’s Occupation

Because the question whether Plaintiff was “totally disabled” depended on whether Plaintiff could “perform the Material and Substantial Duties of his Regular Occupation” the details of his occupation were relevant to the Court’s analysis. According to the job description posted by his employer, the “Technology Development Manager” role had both technical elements and in-person client elements, including business development. The position required not only “managing the technical project team,” but also “interacting with the variety of resources within the organization including application architects, designers, information architects, and client services managers to help insure the successful delivery of the entire project.” The position also required up to 20% travel visiting client sites, conferences, seminars, and training.

Appeals Court Concludes Plaintiff Was In “Regular Attendance” Of A Physician

Under the terms of the Plan, to establish “Regular Attendance,” Plaintiff was required to show both that he “personally visited a Physician as medically required according to standard medical practice, to effectively manage and treat his Disability”; and that he “is receiving the most appropriate treatment and care that will maximize his medical improvement and aid in his return to work.” In American United’s view, despite the great deal of contact Plaintiff had with medical professionals, he was not in “Regular Attendance” under the terms of the Plan because he failed to obtain recommended medical care including a repeat MRI, aqua therapy, and treatment for his chronic pain complaints with pain specialist.

Plaintiff argued that he satisfied the requirement because he received medical treatment routinely from competent physicians, and no evidence suggests that those treatments fell below the standard of care.

The 6th Circuit noted that many courts had concluded that a benefits plan clause that obligates a claimant to be under the “regular care” or in “regular attendance” of a physician does not empower an administrator to micromanage a claimant’s medical care – instead, it exists merely to prevent malingering and fraud. The Court also noted, that where, as here, the provision obligates a claimant to “receive the most appropriate treatment and care” that is designed to “maximize his medical improvement and aid in his return to work,” some courts had concluded that this implies an affirmative duty on the part of the insured to seek and accept care designed to enable the insured to return to his former employment.

To this end, American United argued that a claimant’s failure to pursue any treatment recommended by any medical professional with any level of confidence that the treatment would lead to medical improvement put the claimant outside the realm of “total disability” – even in circumstances when a patient declined treatment that is prohibitively expensive, or experimental, or risky, or painful.

The 6th Circuit did not read the “Regular Attendance” requirement so stringently. Instead, it held that to be in “Regular Attendance” of a physician a patient must pursue all care that is appropriate for a person who is totally disabled. And the record evidence confirmed that Plaintiff had done so. Specifically, the record established that Plaintiff received extensive treatment from medical professionals – including over a dozen visits with his primary care provider and multiple visits with specialists ranging from neurosurgeons to neurologists to physical rehabilitation doctors to pain management doctors.

As for the treatments that Plaintiff allegedly declined to pursue – a second MRI, aqua therapy, and an appointment with one specific pain management specialist – the record offered little to no evidence that Plaintiff would have improved his health outcomes had he pursued them. In short, this was case where the insured made reasonable decisions about his own care and pursued a quantum of treatment one would expect of a person who is totally disabled.

Appeals Court Concludes Plaintiff Was Unable To Pursue His “Regular Occupation”

The second basis upon which DRMS denied Plaintiff’s claim was his alleged failure to prove that he was unable to perform the Material and Substantial Duties of his Regular Occupation. In reaching this conclusion, it reasoned that his occupation of Technology Development Manager was “performed at a sedentary level” and that the available data supported that Plaintiff was capable of performing full time sedentary physical demand level work. 

In reviewing the evidence, the 6th Circuit noted that, although it may not conclude that the opinion of treating physicians is entitled to more weight than that of non-treating physicians, Plan administrators may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician. Moreover, a claimant’s documented limitations may not simply be dismissed as being “subjective exaggerations,” particularly where – as here – the individuals purporting to make that credibility determination did not meet or examine the claimant.

According to the 6th Circuit, the record medical evidence supported the conclusion that Plaintiff was unable to perform his Regular Occupation due to a combination of debilitating back pain as well as the impairing cognitive effect of medication required to treat that back pain. Plaintiff’s subjective level of pain was well-documented: he consistently reported that his pain was debilitating and increasing. More importantly, his pain was documented objectively, including monthly examinations and MRI results as well as testing to confirm Plaintiff was not malingering. Although DRMS affiliated medical professionals determined that the evidence was inconsistent with his reported amount of pain, the 6th Circuit concluded there is no basis upon which to elevate the opinions of DRMS-affiliated practitioners who did not observe or physically assess Plaintiff over those of his treating practitioners.

The Court concluded that it was improbable that Plaintiff was a “good enough actor to fool a host of doctors and emergency-room personnel into thinking he suffered extreme pain, and the (perhaps lesser) improbability that this host of medical workers would prescribe drugs and other treatment for him if they thought he were faking his symptoms. Such an inference would amount to an accusation that the medical workers who treated Plaintiff were behaving unprofessionally.

Moreover, the Court noted that even if Plaintiff were not precluded from sedentary work based on his physical health alone, DRMS could not ignore the “intellectual aspects” of Plaintiff’s job requirements. There was not dispute that Plaintiff’s occupation required a high degree of cognitive capability. DRMS’s own Vocational Consultant described his duties as highly skilled and requiring in-person interaction with co-workers and clients.

American United urged the Court to decline to credit Plaintiff’s treatment provider’s opinion and instead credit the opinion of a physician employed by DRMS who reviewed Plaintiff’s medical records. However, the 6th Circuit concluded that DRMS’s physician’s credibility determination was entitled to little weight because he did a paper review even though the policy gave American United the right to have the claimant examined by an independent doctor.

This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation of disability insurance benefits. Please feel free to contact our office and to speak with one of our disability attorneys for a review of your disability insurance policy and to discuss how we may be able to assist you in securing benefits.