Harmon v. Unum Life Insurance Company of America

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF TENNESSEE

AT CHATTANOOGA

JOEY HARMON, )

)

Plaintiff, )

)

v. ) No.: 1:20-CV-318-KAC-CHS

)

)

UNUM LIFE INSURANCE COMPANY OF )

AMERICA, et al., )

)

Defendants. )

MEMORANDUM OPINION AND ORDER

GRANTING DEFENDANTS’ MOTION FOR JUDGMENT

This case under the Employment Retirement Income Security Act of 1974, 29

U.S.C. § 1001 et seq., (ERISA) is before the Court on (1) the “Motion for Judgment on the Record”

[Doc. 27] filed by Defendants Unum Insurance Company of America and Unum Group

Corporation (collectively, “Defendants”), Plaintiff Joey Harmon’s Response [Doc. 44], and

Defendants’ Reply [Doc. 47]; and (2) Plaintiff’s “Motion for Judgment on ERISA Record”

[Doc. 33], Defendants’ Response [Doc. 46], and Plaintiff’s Reply [Doc. 48]. Plaintiff also filed a

“Motion to Determine Extent of Deference Given to Unum’s Decision” [Doc. 29], which the Court

construes as a supplement to Plaintiff’s “Motion for Judgment on ERISA Record” [Doc. 33]. The

Court has reviewed the full administrative record in this case, which consists of more than 4,500

pages [See Docs. 19-1–19-23]. Because Defendants’ decision to terminate Plaintiff’s claims was

not arbitrary and capricious, the Court GRANTS Defendants’ “Motion for Judgment on the

Record” [Doc. 27] and DENIES Plaintiff’s “Motion for Judgment on ERISA Record” [Doc. 33].

I. Factual Background

Plaintiff previously worked as a facilities technician for 24 Hour Fitness USA, Incorporated

(“24 Hour Fitness”) in Memphis, Tennessee [Docs. 19 at 6, 12; 19-1 at 60]. 24 Hour Fitness

required a “facility technician” to “repair[] and maintain[] all buildings and equipment in assigned

facilities, including operation of all club areas, earning acceptable Audit scores and preventative

maintenance on equipment and facility” [Doc. 19-1 at 43 (Position Description)]. The “physical

requirements” of that role included “lift[ing] a minimum of 50 lbs., bending, squatting, reaching,

or being on feet for long periods of time” [Id. at 44]. On average, Plaintiff earned approximately

$21.93 per hour or $3,801.20 per month at 24 Hour Fitness [Docs. 19 at 6; 19-1 at 223]. Before

his time at 24 Hour Fitness, Plaintiff worked as a “certified pool operator” and “fitness equipment

manufacturer certified technician” [Id. at 145]. On January 6, 2012, Plaintiff suffered an injury to

his back while at work at 24 Hour Fitness [Doc. 19 at 12]. In November, he had back surgery in

Memphis [Doc. 19 at 12, 47-48, 185]. He did not return to work and continued to live in Memphis1

for some time [Docs. 19 at 12; 19-2 at 188]. Plaintiff filed claims for certain disability-related

benefits on April 30, 2014 [Docs. 19-1 at 110, 131; 19-13 at 16].

Defendant Unum Life Insurance Company of America (“Unum”) was the underwriter for

the group long-term disability (“LTD”) policy (“LTD Policy”) and group life insurance policy

(“LWOP Policy”) issued to 24 Hour Fitness [Docs. 19 at 2, 6, 8; 19-1 at 66-108; 19-13 at 39,

41-100; 19-14 1-15]. Defendant Unum Group Corporation is Unum’s parent company

[Docs. 1 ¶ 8; 14 ¶ 8]. Both LTD and LWOP Policies stated:

The Plan, acting through the Plan Administrator, delegates to Unum and its

affiliate Unum Group discretionary authority to make benefit determinations

1 Plaintiff reported that he (1) “had moved to Memphis for the job,” (2) “rent[ed] his own home to

pay for the mortgage,” (3) “[s]ta[y]ed with relatives in FL,” and (4) “lived” in Florida from January

2013 through April 2014 [Docs. 19-1 at 60; 19-2 at 156; 19-16 at 36].

under the Plan. Unum and Unum Group may act directly or through their

employees and agents or further delegate their authority through contracts, letters

or other documentation or procedures to other affiliates, persons or entities. Benefit

determinations include determining eligibility for benefits and the amount of any

benefits, resolving factual disputes, and interpreting and enforcing the provisions

of the Plan. All benefit determinations must be reasonable and based on the terms

of the Plan and the facts and circumstances of each claim.

[Docs. 19-1 at 104; 19-14 at 11 (emphasis added)]. Under the LTD and LWOP Policies, Unum

evaluated claims and made any payments directly to the employee beneficiary [Docs. 19-1 at 74;

19-3 at 55].

Both Policies provided benefits when a claimant qualified as “disabled.” The LTD Policy

provided disability payments [Doc. 19-1 at 82-84]. As relevant here, the LTD Policy defined

“disabled,” as “[a]fter 24 months of payments”:

[W]hen Unum determines that due to the same sickness or injury, you are unable

to perform the duties of any gainful occupation for which you are reasonably fitted

by education, training or experience.

[Id. at 82 (emphasis added)]. It defined “gainful occupation” as:

[A]n occupation that is or can be expected to provide you with an income within

12 months of your return to work, that exceeds: 80% of your indexed monthly

earnings, if you are working; or 60% of your indexed monthly earnings, if you are

not working.

[Doc. 19-1 at 95 (emphasis added)]. The LWOP Policy provided that if an employee qualifies as

“disabled,” Unum would waive certain premiums [Doc. 19-13 at 44, 76]. The LWOP Policy

defined “disabled” as, nine (9) months after “a period of continuous disability,”

[D]ue to the same injury or sickness, you are unable to perform the duties of any

gainful occupation for which you are or become reasonably fitted by training,

education or experience and which disability is, in fact, preventing you from

engaging in any employment or occupation for wage or profit.

[Doc. 19-13 at 76-77, 100]. It defined “gainful occupation” as

[A]n occupation that within 12 months of your return to work is or can expected to

provide you with an income that is at least equal to 60% of your annual earnings

in effect just prior to the date your disability began.

[Doc. 19-13 at 100 (emphasis added)]. Neither Policy defined a particular market that Unum

would use to determine the rate for “gainful occupation.” The Policies provided that Unum

(1) “may require you to be examined by a physician, other medical practitioner, [and]/or vocational

expert of our choice,” (2) “can require an examination as often as it is reasonable to do so,” and

(3) “may also require you to be interviewed by an authorized Unum Representative”

[Docs. 19-1 at 82; 19-13 at 78].

The LTD Policy provided that LTD payments would end, as pertinent here, “on the earliest

of the following”:

- the date you are no longer disabled under the terms of the plan;

- the date you fail to submit proof of continuing disability;

[Doc. 19-1 at 87]. Likewise, the LWOP Policy provided that Unum would no longer waive

premiums if, as pertinent here:

- you recover and you no longer are disabled;

- you fail to give us proper proof that you remain disabled;

[Doc. 19-13 at 77].

The Policies also provided a mechanism to appeal an adverse decision. On appeal, Unum

would “take into account all new information” and afford “[n]o deference” “to the initial

determination” [Docs. 19-1 at 102; 19-14 at 8-9]. “[A] different person from the person who made

the initial determination” would conduct the appellate review, and that person “will not be the

original decision maker’s subordinate” [Docs. 19-1 at 102; 19-14 at 9]. If Unum denied the initial

claim “on the grounds of a medical judgment,” then, on appeal, Unum would “consult with a health

professional with appropriate training and experience” who is not the individual “consulted during

the initial determination or a subordinate” [Docs. 19-1 at 102; 19-14 at 9].

To evaluate whether Plaintiff qualified as “disabled,” Unum received records from

Plaintiff’s treatment providers, and a Unum vocational rehabilitation consultant (“VRC”)

completed a vocational assessment (“VA”) [Doc. 19-18 at 48]. Plaintiff’s orthopedic surgeon, Dr.

Jonathan A. Hyde in Miami, Florida, concluded that Plaintiff achieved medical maximum

improvement (“MMI”) status for Plaintiff’s diagnosis of “post laminectomy syndrome” in May

2013 [Docs. 19 at 12, 45; 19-1 at 142]. Dr. Hyde saw Plaintiff seven (7) times in 2013 for various

“low back pain complaints” [See Doc. 19-3 at 124, 128, 129, 134, 141, 145, 147, 152, 156, 161-62].

An August 17, 2013 MRI of Plaintiff’s lumbar spine showed evidence of “disc bulges from L3-S1

with L5/S1 disc bulge asymmetric to the left deforming left paracentral thecal sac and contacting

left S1 nerve root” [Id. at 168-69].

During Dr. Hyde’s last visit with Plaintiff on November 4, 2013, Dr. Hyde (1) reported

“[n]o change in restrictions or maximum medical improvement date” and (2) permanently

restricted Plaintiff to “moderate work demand with no lifting greater than 35 lbs.”

[Docs. 19-1 at 34; 19-16 at 51]. The VA classified Plaintiff’s occupation within a “Facilities

Maintenance” category, which involved “perform[ing] at the medium physical demand level

(lifting, carrying, pushing, pulling 20-50 lb. occasionally, 10-25 lb. frequently or up to 10 lb.

constantly)” and “sitting, stopping (bending), kneeling, crouching, crawling, climbing, and

balancing – occasionally; and reaching (a combination of all directions), standing and

walking – frequently” [Doc. 19-1 at 136].

On May 26, 2014, Unum Senior Clinical Consultant Diane Suess concluded that it was

“reasonable” that Plaintiff “would not have been able to perform” his occupational duties at 24

Hour Fitness [Doc. 19-18 at 46-49]. Suess viewed Dr. Hyde’s November 2013 permanent

thirty-five-pound (35-pound) restriction as “reasonable” because Plaintiff’s “back pain has not

resolved” “[d]espite conservative treatment and surgical intervention,” and “his functional

capacity is unlikely to change or improve” [Doc. 19-18 at 48-49]. Suess also reviewed an April

30, 2014 workers’ compensation2 independent medical evaluation (“IME”) by orthopedic surgeon

Dr. Apurva R. Dalal that concluded Plaintiff “should avoid lifting any weight more than 10

pounds” and “avoid bending, pulling, pushing and lifting” [Doc. 19-1 at 161, 164]. Based on the

IME, Suess remarked that Plaintiff’s “clinical picture has worsened” since Dr. Hyde’s final

evaluation because of the reported “severe muscle spasms, decreased sensation” “on the left side,”

and “radiculopathy with loss of strength in the left lower extremity” [Doc. 19-18 at 50]. Suess

viewed the IME’s ten-pound (10-pound) restriction as “reasonable,” and recommended that

Plaintiff “avoid bending, pulling, pushing and lifting” [Id.]. Based on Suess’s evaluation of

Plaintiff’s medical records and VA, Unum approved Plaintiff’s claims for LTD and LWOP

benefits on June 6, 2014 [See Docs. 19-2 at 67-74; 19-13 at 11; 19-18 at 65, 71-72].

Over the next few years, Unum continued to evaluate Plaintiff’s claims and pay him

benefits under the “gainful occupation” definition of “disabled.” On August 15, 2014, a new VRC

reviewed Plaintiff’s “skills for gainful alternate occupations within the Sedentary or Light physical

demand level” based on Plaintiff’s residence in Memphis3 [Doc. 19-2 at 188]. The VRC also

reviewed Plaintiff’s former occupation, qualifications, and education [Id.]. The VRC found it

2 Plaintiff and 24 Hour Fitness reached a workers’ compensation settlement agreement on May 30,

2014 [See id. at 58-63]. The agreement listed Plaintiff as a “resident of Dade County” who “resides

in Miami, FL” [Id. at 59].

3 During a call on September 17, 2014 with his disability benefits specialist, Plaintiff reported that

he “travels to Florida for assistance,” “has family in Florida,” and visited Florida approximately

two (2) times each year [Doc. 19-2 at 193].

“unlikely” that Plaintiff “would have sufficient skills for gainful alternate occupations within the

Sedentary or Light physical demands” [Id.]. In October 2015, Plaintiff reported that his “back

pain is still present,” and he reported restrictions related to “[l]ifting, sitting, walking,” and

“standing” [Id. at 235]. In May 2016, Unum Director Wesley Ridlon recommended “capacity

review” [Doc. 19-3 at 30]. Based on Plaintiff’s location in Memphis, Senior VRC Norma

Parras-Potenzo conducted a skills assessment and calculated Plaintiff’s gainful occupational

earnings. She concluded that “less physically demanding occupations” “would not provide a

gainful [occupation] wage of $13.54 per hour in Memphis” [Id. at 42].

Both Parties remained in status quo through Summer and Fall 2016. On May 27, 2016,

Unum attempted to mail Plaintiff a letter about its ongoing evaluation of his claims [Id. at 48]. A

month later, Plaintiff reported that he “never got [Unum’s] letter” because he was “in Florida right

now” [Id. at 53]. He “provided a temporary address” in Florida “to use for the time being” [Id.].

Unum added that “temporary address” to Plaintiff’s file [See Doc. 19-18 at 81]. In a July 24, 2016

letter to Unum, Plaintiff detailed “a level of pain and discomfort 24 hours daily” that he alleviated

through icing and “light workouts every other day” [Doc. 19-3 at 71 (describing “3 forms” of

exercise and a daily activity list), 121]. On August 15, 2016, Plaintiff’s primary care physician,

Dr. Harris Mones in Miami, Florida, provided Unum Plaintiff’s medical records [Id. at 196].4 In

visits with Dr. Mones, Plaintiff reported “waxing and waning” back pain [Id. at 200]. When asked

by Unum to clarify Plaintiff’s “work capacity,” Dr. Mones stated that Plaintiff “should follow up

in the clinic” [Id. at 219]. A week later, Dr. Mones provided that Plaintiff could not perform

4 Plaintiff had not seen Dr. Hyde, his orthopedic surgeon since November 2013, when Dr. Hyde

kept Plaintiff at his MMI with the then-existing thirty-five-pound (35-pound) weight restriction

[See id. at 124, 128, 129, 134, 141, 145, 147, 152, 156, 161-62].

certain work demands because he “[w]as given a maximum 35 lb lifting restriction,” referencing

Dr. Hyde’s November 2013 permanent work restriction [Doc. 19-4 at 27].

On August 30, 2016, Unum Director Ridlon remarked that Plaintiff “is not in active

treatment at this time” and recommended an “activities check” to determine Plaintiff’s “level of

activity” [Id. at 30]. Contractors for Unum attempted to observe Plaintiff at the address he

provided in Miami but could not complete a review [See id. at 39]. A September 14, 2016 Medical

Issue Statement by Unum Senior Clinical Consultant Deborah C. Ainscough, a registered nurse,

provided that Plaintiff “continues” to report lower back pain “causing decreased level of activities”

[Id. at 51-54]. Based on Dr. Hyde’s 2013 restriction and Plaintiff’s continued self-reports of pain,

Nurse Ainscough found it “reasonable” that Plaintiff “is precluded from lifting > 35 lbs” [Id. at 54].

As of September 15, 2016, Unum—through Director Ridlon—recommended transferring

Plaintiff’s case for ongoing review based on Nurse Ainscough’s conclusions [Id. at 61].

On February 2, 2017, an Administrative Law Judge (ALJ) for the Social Security

Administration (SSA) denied a disability claim Plaintiff submitted [Id. at 71].5 The ALJ concluded

that although Plaintiff had a “severe impairment,” specifically, “degenerative disc disease,”

Plaintiff “ha[d] not been under a disability within the meaning of the Social Security Act”

[Id. at 74, 76]. The ALJ determined that Plaintiff’s “statements concerning the intensity,

persistence and limiting effects” of his symptoms were “not entirely consistent with the medical

evidence,” which reflected “improvement in symptoms after surgery” and “few complaints of

limitations in functioning” [Id. at 78-79]. Based on this evidence, the ALJ concluded that Plaintiff

had “the capacity for work activity,” including “light work” [Id. at 80]. The ALJ provided

5 Plaintiff received the ALJ’s decision at a residence in Miami, Florida [Id.].

three (3) positions that Plaintiff “would be able to perform” considering his “age, education, work

experience, and residual functioning capacity” [Id. at 81].

After the ALJ’s decision, Unum recommended “evaluating” Plaintiff’s claims for

eligibility [Id. at 92]. Unum Director Jo-Anne Copeland and a VRC reviewed the occupations

identified in the ruling [Id.]. But they determined that those occupations “when reviewed in current

labor market or past would not meet the gainful [occupation] wage” [Id.]. They recommended

“revisit[ing] the vocational aspect” “in 12 months as wages may increase or other occupations may

be appropriate to consider at that time (possible full skills assessment)” [Id.].

The situation changed in Fall 2017. On September 22, 2017, Plaintiff provided a

“[c]onfirmed address” in Miami, Florida, and he reported “liv[ing] in downtown Miami”

[Id. at 97-98]. He stated that he “no longer participat[ed] in physical therapy” but did “his own

exercises,” including “30-45 minutes every single day” and “normally lift[ing] about 10-15

pounds” “repetitively” [Id. at 97]. Plaintiff had not returned to work because of “the pain” and his

“need[] to rest” and “‘respect’ his injury” [Id. at 98].

Unum continued to review the situation. As part of the review process, Senior VRC

Parras-Potenzo “revisit[ed] the skills assessment” to determine whether Plaintiff “ha[d] skills for

[an] alternate gainful occupation” or a “less physically demanding” occupation given the “new

labor market” in Miami, Florida, where Plaintiff “presently reside[d]” [Id. at 103-04]. Parras-

Potenzo analyzed various items, including Plaintiff’s prior position with 24 Hour Fitness, the

duties of that position, Plaintiff’s medical restrictions, the SSA ALJ’s findings, and Plaintiff’s

employment history, related certifications, and occupational competencies [See id. at 104]. Based

on this analysis and the existing record, Parras-Potenzo concluded that Plaintiff “would have skills

for alternate occupations which are performed with occasional lifting up to 20 pounds, frequently

up to 10 pounds; frequent sitting with occasional standing, walking with ability to make positional

ch[an]ges” [/d. at 104-05].

With this new analysis, Unum transferred Plaintiffs file for “medical and vocational

review,” which involved acquiring a new round of medical documentation [/d. at 106-08]. Dr.

Mones—who Plaintiff confirmed was his only treating provider at the time—provided updated

records [See id. at 119]. Dr. Mones saw Plaintiff twice in September 2017 for reports of pain in

Plaintiffs back, right elbow, right shoulder, and right knee after a car accident [/d. at 133]. An x-

ray of Plaintiff's lumbar spine was “unremarkable,” with “preserved disc spaces,” “[n]ormal

alignment,” and no “degenerative change” [/d. at 135-36]. At the second appointment, Plaintiff

reported that he “ha[d] improved significantly,” “ha[d] not started any physical therapy,” and “his

shoulder [wa]s still aching slightly but all other pains [we]re much better” [/d. at 135; see also id.

at 149 (Plaintiff stated in a call that he “ha[d] not attended any” physical therapy and “d[id]n’t feel

he will need to” attend physical therapy)].

In addition, Unum asked Dr. Mones to provide his opinion regarding Plaintiff's ability to

return to work under certain conditions. Specifically, on October 11, 2017, Unum sent the below

inquiry to Dr. Mones:

We are interested in whether you would agree that Mr. Harmon has the physical ability to return

to work and whether you would release him to return to work full time (8 hours/day, 5

days/week) in an occupation with the following demands:

e Occasional lifting up to 20 pounds, frequently up to 10 pounds.

e Frequent sitting with occasional standing, walking with ability to make positional

changes.

Definitions of Frequency per the Revised Handbook for Analyzing Jobs:

‘Occasionally’= up to 1/3 of a work day (0 - 2.5 hours a day in an 8-hour workday)

‘Frequently’ = up to 2/3 of a work day (2.5 - 5.5 hours a day in an 8-hour workday)

‘Constantly’ = over 2/3 of a work day (5.5+ hours a day in an 8-hour workday)

1 Agree: | Do Not Agree:

10

at 121, 129-30]. The second page of the inquiry provided a space for Dr. Mones to sign and

date the form [/d. at 122].

After Unum did not receive a response from Dr. Mones, Unum called Dr. Mones on

October 18 [/d. at 141]. A representative from Dr. Mones’s office stated that Dr. Mones “didn’t

receive the request” and asked Unum to fax the request again [/d.]. On October 23, Dr. Mones’s

office faxed the following to Unum:

| Agree: | Do Not Agree:

If you do not agree, please provide your rationale: host eurendt

We pwr b tetrer bef. Cle &r eval

□□ Ue prior HS ROtaraYy hy Work.

[/d. at 143-44]. Then on October 30, Dr. Mones’s office faxed the below to Unum:

We are interested in whether you would agree that Mr. Harmon has the physical ability to return

to work and whether you would release him to retum to work full time (8 hours/day, 5

days/week) In an occupation with the following demands:

e Occasional lifting up to 20 pounds, frequently up to 10 pounds.

e Frequent sitting with occasional standing, walking with abliity to make positional

changes.

Definitions of Frequency per the Revised Handbook for Analyzing Jobs:

‘Oceaslonally'= up to 1/3 of a work day (0 - 2.5 hours a day In an 8-hour workday)

‘Frequently’ = up to 2/3 of a work day (2,5 » 5.5 hours a day in an 8-hour workday)

‘Constantly’ = over 2/3 of a work day (5.5+ hours a day in an 8-hour workday)

| Agree:_\/ 1Do NotAgree;_

[/d. at 152-53]. Dr. Mones did not sign or date either the October 23 or October 30 form.

Having received both the October 23 and October 30 forms that stated different

conclusions, Unum left a message for Dr. Mones on October 30 [/d. at 161]. Unum asked whether

Dr. Mones evaluated Plaintiff “between the 23rd and the 30th” of October and whether the October

30 form represented Dr. Mones’s “most current opinion” because “both responses received did not

include [Dr. Mones’s] signature or date” [/d.]. Unum requested that Dr. Mones “refax the form”

11

with his signature and date [/d.]. On October 31, Unum Director Ridlon spoke with Dr. Mones

who confirmed that he had not seen Plaintiff since September 2017, and Plaintiff “d[id] not have

a follow-up appointment” scheduled “at this time” [/d. at 163].

On November 2, Unum again called Dr. Mones’s office to ask whether Dr. Mones’s

October 30 form represented his “most recent opinion” [/d. at 169]. Dr. Mones’s medical assistant

answered and stated that Dr. Mones would call Unum back [/d.]. Later that day, Dr. Mones’s

physician’s assistant called Unum back and appears to have stated that the “10/30/2017 opinion”

“is the most recent opinion” but that Dr. Mones “d[id] not have” a “revised Physician’s Narrative”

to review [/d. at 179]. To confirm, on November 3, Unum sent yet another form to Dr. Mones:

We are continuing our review of Joey Harmon's disability claim and would appreciate your

assistance in providing additional information.

On October 30, 2017, we received the attached response from you indicating you agree Mr.

Harmon can perform the demands outlined and are releasing him to return to work full time.

Does this continue to be your current opinion?

Yeas No lamnotcommenting_

ifno, please explain.

SN

[/d. at 177]. By November 13, 2017, Unum had not received a response from Dr.

Mones [/d. at 183].

In the meantime, on November 3, Unum Senior Clinical Consultant Nurse Ainscough

performed a Clinical Analysis based on Plaintiffs self-reported activities and clinical records,

12

including Plaintiff’s last MRI from August 2013, Dr. Hyde’s November 2013 restriction, and Dr.

Dalal’s 2014 IME [See id. at 165-68]. In reviewing Dr. Mones’s records, Nurse Ainscough noted

(1) “there are no physical exam findings documented other than” Plaintiff’s “reports of pain” and

(2) Plaintiff’s September 22, 2017 “Lumbar spine Xray shows normal alignment with disc space

well preserved and no degenerative change” [Id. at 167]. Nurse Ainscough also noted Dr. Mones’s

“10/30/2017 release” to a “functional capacity” “which is less than had been evaluated” in a former

clinical review [Id.]. Nurse Ainscough concluded “there is no current medical documentation” to

support Plaintiff “be[ing] precluded from” “occasional lifting up to 20 pounds, frequently up to 10

pounds; frequent sitting with occasional standing, walking with ability to make positional

changes” [Id. at 167-68].

Also on November 3, Unum VRC Carrie Cousins conducted a vocational review of

Plaintiff’s file “to determine whether another occupation exists” that Plaintiff “could reasonably

be expected to perform satisfactorily in light of his[] age, education, training[,] experience[,]

station in life, physical and mental capacity” [Id. at 172]. To do so, Cousins reviewed Unum’s

initial skills assessments and the two (2) skills revisits, the gainful occupation calculations, Nurse

Ainscough’s Clinical Analysis, Plaintiff’s communications with Unum representatives, and

Plaintiff’s work history, skills, and qualifications [Id. at 172]. Cousins evaluated Plaintiff’s file

based on his residence in Miami [Id. at 173]. She evaluated certain potential gainful occupations,

specifically, “Inspector Component Parts,” “Final Inspector,” and “Security Guard,” based on

Plaintiff’s “demonstrated skills/knowledge” and his “training, education, and experience”

[Id. at 173-74]. She noted Plaintiff could perform these occupations “within the functional

capacity” of “[o]ccasional lifting up to 20 pounds, frequently up to 10 pounds; frequently sitting

with occasional standing,” and “walking with ability to make positional changes” [Id. at 173].

Plaintiff would not need further training for the occupations because they would be “consistent

with” Plaintiff’s “work history,” “certificates,” and “high school diploma” [Id.]. These positions

“provide[d] a wage range of $13.57 to $15.28 per hour,” which “exceeds 60% of pre-disability

earnings” [Id.].

On November 15, 2017, Unum recommended a “non-compensable decision” based on

Cousins’s vocational review, Dr. Mones’s October 30 opinion, and Nurse Ainscough’s clinical

analysis [Id. at 185]. Quality Compliance Consultant Elaine Brooks approved the

recommendation [Id. at 185-86]. She reasoned that Dr. Mones “released” Plaintiff “to full time

light functional range,” Plaintiff’s medical records and self-reported activity level are “consistent”

with that functional capacity, and the vocational assessment “identified occupations” Plaintiff

could “perform that are consistent with gainful occupations” and “do not exceed his functional

capacity” [Id. at 186].

In November 2017, Unum stopped providing benefits to Plaintiff under both the LTD and

LWOP Policies. On November 17, Unum informed Plaintiff that it could not continue paying

LTD benefits because Unum determined that Plaintiff could “perform the duties of other gainful

occupations” and was therefore “not disabled under the policy” [Id. at 189-90]. Unum relied on

Dr. Mones’s October 30 opinion, Nurse Ainscough’s clinical analysis, Plaintiff’s “reported daily

activities,” its vocational analysis, and the SSA ALJ’s denial of Social Security disability benefits

in making this determination [Id. at 190-91]. And on November 20, Unum informed Plaintiff that

it could not continue to waive the life insurance premium under the LWOP Policy because Unum

determined that Plaintiff could “perform the alternate gainful occupations” and was therefore “no

longer disabled” under that Policy [See Doc. 19-20 at 44-45]. In making this determination, Unum

“reviewed information contained in” Plaintiff’s LTD claim file [Id. at 45].

Plaintiff appealed Unum’s determination, submitting to Unum a list of 162 “[p]roblems”

and a separate “Appeal Summary” outlining nineteen (19) disputes and rebuttals [See Docs. 19-5

at 13-250; 19-6 at 1-250; 19-7 at 1-127, 133-250; 19-8 at 1-177, 180-250; 19-9 at 1-111, 115-84,

187-250; 19-10 1-114, 116-250; 19-11 at 1-196; 19-20 at 60-200; 19-21 at 1-158, 161-200; 19-22

at 1-200; 19-23 at 1-74]. Some “problems” related to Unum’s evaluation of Plaintiff’s condition,

including that Unum did not sufficiently consider Plaintiff’s level of pain [See Doc. 19-5 at 16].

Others focused on a lack of “therapy notes” from certain providers, including an authorized

provider for Plaintiff’s workers’ compensation claim, orthopedic surgeon Dr. Kenneth Jarolem

[Id. at 17; Doc. 19-20; 19-7 at 133]. Plaintiff provided records from an April 19, 2018 appointment

with Dr. Jarolem, indicating that Dr. Jarolem limited Plaintiff to “work restrictions of no lifting

over 5 pounds” [Doc. 19-8 at 190]. Plaintiff also stated that “TN is the labor market” and that he

“provided a TEMPORARY address in FL for the time being” [Doc. 19-7 at 134, 136]. Plaintiff

referenced Dr. Mones’s October 2017 opinions and included a new January 26, 2018 letter from

Dr. Mones that sought “to clarify [his office’s] medical records,” specifically explaining that:

[W]e are in possession of a fax regarding patient Joey Harmon that was dated

October 23, 2017. This fax was in fact sent by my physician assistant to UNUM

where we clearly state when asked whether it is our position that the patient is

physically able to return to work, we clearly check the box that states “I do not

agree.” Additionally, in my physician assistants [sic] handwriting it states “the

patient needs to return to the clinic for evaluation on current capabilities prior to

returning to work.”

I am in possession of another fax dated October 30, 2017 where the box was

checked “I agree” that the patient can return to work. No where [sic] on that form

is there any designation that I or my physician assistant completed the form. We

have no recollection of ever seeing a second form until most recently.

Based upon a review of this patient’s prior medical records, it is my opinion that

the patient is in fact unable to return to work.

[Doc. 19-8 at 203].

To evaluate Plaintiff’s appeal, Unum reassigned Plaintiff’s LTD and LWOP file to a

separate appeals team [See Doc. 19-11 at 202-06]. Unum requested and received additional

records from Dr. Mones for Plaintiff’s visits after November 2017

[See Docs. 19-11 at 213-19-12 at 25]. Dr. Mones saw Plaintiff on December 21, 2017 to discuss

the two (2) forms Dr. Mones’s office sent to Unum in October 2017 [See Doc. 19-11 at 224].

During the December 21 appointment, Dr. Mones noted that Plaintiff had a “long history of back

pain” related to a “herniated disc” that “continues” to “bother[]” Plaintiff [Id.]. Dr. Mones wrote

that when he saw Plaintiff in September 2017, Plaintiff “d[id] not complain[] of back pain but had

other musculoskeletal complaints secondary to the trauma of the motor vehicle accident,” which

“have improved” [Id.]. During the December 21 examination, Dr. Mones reported that Plaintiff

had “limited mobility of the lumbar spine with muscle spasm otherwise unremarkable” [Id. at 225].

Dr. Mones further wrote that he would “review” Plaintiff’s “paperwork” and “contact the

insurance carrier” [Id.]. Dr. Mones “advised” Plaintiff that his office “ha[d] no recollection of any

faxes” stating that Plaintiff “could return to work as we did not address his low back issues” [Id.].

After the December 21 visit, Dr. Mones saw Plaintiff on (1) January 26, 2018 for “bilateral

foot pain” “around the cuticles of all his toes,” (2) February 1, 2018 for “results,” (3) and June 4,

2018 for Plaintiff’s annual physical [Id. at 219-21]. At the annual physical on June 4, 2018,

Plaintiff was “without complaints,” “denie[d] back pain,” and had “full range of motion” in his

“lumbar spine” [Id. at 223-24]. On June 22, 2018, Dr. Mones noted that Plaintiff “has also been

seeing his orthopedic Dr. Kenneth Jarolem for his on going [sic] back pain” [Doc. 19-12 at 54].

Unum also requested and received Plaintiff’s medical records from Dr. Jarolem dating back

to 2016 [Id. at 31, 33]. Dr. Jarolem only saw Plaintiff twice, and both of those appointments

occurred in 2018—after Unum terminated Plaintiff’s benefits [Id. at 33-37]. On April 19, 2018,

Plaintiff saw Dr. Jarolem for “low back pain” “going down into left leg” [Id. at 37]. Dr. Jarolem

wrote that he had seen Plaintiff “in the remote past for similar complaints” [Id.]. During a physical

examination, Dr. Jarolem noted “tenderness across the lumbosacral junction” and that “[s]traight

leg raising on the left produced pain at the posterior lateral calf” but there were “no deficits” [Id.].

X-rays of Plaintiff’s lumbar spine revealed “a neutral alignment” [Id.]. Dr Jarolem diagnosed

Plaintiff with “[l]ow back pain,” “[i]ntervertebral disc disorders with radiculopathy, lumbar

region,” “[l]umbago,” and “[o]ther unspecified disc disorder, lumbar region” [Id. at 38]. Dr.

Jarolem recommended physical therapy and stated that Plaintiff “remains with work restriction of

no lifting over 5 pounds” [Id.]. On May 24, 2018, Dr. Jarolem saw Plaintiff for a follow-up

appointment relating to Plaintiff’s “[l]ow back pain with left posterior thigh radiation” [Id. at 34].

Plaintiff reported that he had not started physical therapy [Id.]. At the appointment, Plaintiff “noted

substantial increase in his overall pain” with “no known inciting event” [Id.]. Dr. Jarolem noted

“diffuse tenderness across the lumbosacral junction” and that “[s]traight leg raising on the left

produced back and buttock pain” but “no motor defects” [Id.]. Dr. Jarolem stated that Plaintiff

“remains with work restrictions of no lifting over 5 pounds” [Id.].

Unum then referred Plaintiff’s file for a medical and forum review “to determine if

[restrictions and limitations] precluding light level work are supported beyond 11/17/17, and to

discuss if peer contact is needed with Dr. Jarolem” [Id. at 75-76]. Unum Director Craig Johnson

recommended (1) contacting Dr. Mones to “clarify” his “notes” about releasing Plaintiff to work

and (2) “review[ing] records” from Dr. Jarolem [Id. at 78]. Because Plaintiff “was not in active

treatment” with Dr. Jarolem “from 12/2015 to 4/2018,” Director Johnson determined that Unum

did not need to contact Dr. Jarolem [Id.]. Director Johnson recommended that a clinical consultant

“review” the records and “refer[]” them to an Unum on-site physician “to evaluate” [Id.].

Unum Appeals Senior Clinical Consultant Tina Marie Tirabassi, a registered nurse,

conducted “a full review of the medical record” and Nurse Ainscough’s clinical analyses in 2016

and 2017 to inform Nurse Tirabassi’s own “independent analysis” and conclusions [Id. at 82-83].

Nurse Tirabassi noted that Dr. Jarolem’s medical records are only from “approximately five

months after” Unum denied Plaintiff’s claims [Id. at 83]. Plaintiff did not see Dr. Jarolem from

2016 to November 2017 when Unum denied Plaintiff’s claims [Id.]. Nurse Tirabassi also noted

that Plaintiff had an IME in 2014 with Dr. Dalal, which resulted in lifting restrictions of ten (10)

pounds [Id. at 85]. Since then, however, “there have been no recommendations” for any clinical

procedures or “any medication changes” despite Plaintiff’s continued “radiating complaints” [Id.].

Nurse Tirabassi also noted that Plaintiff “has not followed up with” physical therapy “as would be

expected given complaints and reported impact on functioning” [Id.]. Additionally, “[r]epeated

diagnostics” “have not changed over time” and “[e]xams over time” “have been normal” [Id.].

Nurse Tirabassi remarked that “[t]he frequency” of Plaintiff’s visits with Dr. Mones for Plaintiff’s

“back complaints and impact on functioning” combined with the “lack of any other treating

providers does not indicate a severity of findings precluding the below level of outlined

functioning” [Id.]. She concluded that “[i]t is unclear” why Plaintiff “would not be able to have

the . . . outlined functional capacity” and deferred to the on-site physician “for additional analysis

and comment” regarding Plaintiff’s reported “radiating low back pain” [Id. at 85-86].

Unum on-site physician, Dr. Beth Schnars, a board-certified doctor of internal medicine,

then reviewed Plaintiff’s file. Dr. Schnars “completed a full review of the medical record,”

including Nurse Tirabassi’s clinical report and Nurse Ainscough’s two (2) prior clinical analyses,

to conduct Dr. Schnars’s own “independent analysis” and “form[]” Dr. Schnars’s own conclusions

[Id. at 90]. Dr. Schnars addressed Dr. Hyde’s 2013 thirty-five-pound (35-pound) lifting restriction,

Dr. Dalal’s 2014 IME and ten-pound (10-pound) lifting restriction, and Dr. Jarolem’s 2018

five-pound (5-pound) lifting restriction [Id. at 90-92]. She concluded that medical records fail to

support each restriction and “do not describe significant abnormalities of physical exam, frequency

of evaluation or intensity of treatment” [Id. at 91]. Dr. Schnars opined that Dr. Dalal’s 2014

restriction was “inconsistent with other provider[s]” and “MRI studies” [Id. at 92]. She likewise

concluded that restrictions by Dr. Hyde in 2013 and Dr. Jarolem in 2018 were inconsistent with

Plaintiff’s “[l]evel of personal activity”—including “work[ing] out” for “30-45 minutes/day” and

lifting ten (10) to fifteen (15) pounds—and the “underlying organic pathology on prior MRI

studies,” namely, Plaintiff’s last MRI in 2014 [Id.]. In reviewing Plaintiff’s medical records from

Dr. Mones, Dr. Schnars noted “very limited mention of chronic pain issues,” “[n]o additional pain

medication,” “limited” “[m]usculoskeletal exams,” and “unremarkable X-rays” [Id.]. She also

noted that Plaintiff obtained “no additional subspecialty evaluations” for his low back pain from

November 2013 to April 2018 [Id.]. She acknowledged Plaintiff’s asserted “substantial

limitations,” but she nonetheless concluded that the “medical records,” “exam findings,” “limited

pain management,” a “paucity of axial/neurologic exams,” and “large gasp [sic] in subspecialty

evaluation” are collectively “inconsistent” with the “severity of reported pain” [Id.]. Ultimately,

Dr. Schnars concluded that “[b]ased on the weight of the medical evidence submitted, there is no

physiologic evidence to support ongoing impairment which would support inability to perform”

the functional requirements of “[o]ccasional lifting up to 20 pounds, frequently up to 10 pounds;

frequent sitting with occasional standing, walking with ability to make positional

changes” [Id. at 91].

Dr. Schnars specifically addressed Dr. Mones’s opinion. She attempted to contact Dr.

Mones by phone on July 12, 2018 [Id. at 94]. When Dr. Schnars did not reach Dr. Mones, Dr.

Schnars sent Dr. Mones a fax detailing her medical opinions and making specific inquiries as set

forth below.

itis my opinion that the medical records do not support ongoing impairment which would

preclude full time work capacity from 11/18/17 onward at the light level as defined below:

@ Occasional lifting up to 20 pounds, frequently up to 10 pounds; frequent sitting with

occasional standing, walking with ability to make positional changes

You have opined in your letter of advocacy dated 1/26/18 that Mr. Harmon was unable to work.

Other than Mr. Harmon's reports of limitations fram chronic LBP, what additional medical

information and/or diagnostic testing did you rely on to base your opinion that he cannot

work?

Is there any medical reason that the claimant could not work if they wanted too?

[/d. at 90-92, 96]. In response, Dr. Mones wrote:

During our examination on 12/21/2017 of patient Joey Harmon . . . at which time

we also reviewed the patients [sic] prior medical records, it was my opinion that

the patient is in fact unable to return to work. That opinion is based upon the records

from other medical facilities that were reviewed in addition to my exam on

12/21/17. As stated in my letter January 26, 2018. [sic] It is in [sic] my opinion

that that patient is in fact unable to return to work.

[/d. at 107]. Dr. Schnars reviewed Dr. Mones’s letter and stated “[t]here was little elaboration as

to the reasoning” for Dr. Mones’s opinion beyond Dr. Mones’s “review of the medical records and

the 12/17 exam which were very limited in scope” [/d. at 109]. Dr. Schnars therefore concluded

that Dr. Mones’s “response does not alter [her] previous opinion” [/d. ].

On August 9, 2018, Unum informed Plaintiff that it “determined the decisions on

[Plaintiffs] claims are correct” because Plaintiff was “able to perform the duties of alternate

gainful occupations” and therefore “no longer me[]t the policy definitions of disability” [/d. at 116;

Doc. 19-23 at 90]. The decision referenced Dr. Schnars’s evaluation of Plaintiff's appeal,

including Plaintiffs records and the restrictions recommended by Dr. Hyde, Dr. Dalal, Dr. Mones,

20

and Dr. Jarolem [Id. at 117-18]. It also referenced the SSA ALJ’s determination that Plaintiff did

not qualify as “disabled” under the Social Security Act [Id. at 118]. And it referenced Plaintiff’s

self-reported activity levels in conjunction with his “substantial limitations” [Id.]. The decision

specifically addressed Plaintiff’s “appeal letter” and “multiple exhibits” [Id. at 119]. Unum stated

that Dr. Schnars “attempted to contact Dr. Mones,” “sent a letter” to him, and received his “written

response” but concluded that Dr. Mones’s “response did not change” Dr. Schnars’s opinion

[Id. at 120]. Unum also stated that Dr. Jarolem’s records did not reflect that Plaintiff “w[as] in

active treatment” when Plaintiff’s benefits ended, “with a gap in treatment from December 2015

to April 2018” [Id.]. Finally, Unum addressed Plaintiff’s change in address, stating that Plaintiff

“provided a Florida mailing address,” did not “advise[] that” the “mailing address should be

changed back” to Tennessee, and listed a mailing address in Miami, Florida in a November 26,

2017 letter “requesting a copy” of the claim file [Id.]. Unum concluded that “the decision to deny

benefits” on Plaintiff’s claims was “appropriate” and that the record “supports” a conclusion that

Plaintiff was “able to perform the duties of the identified alternate gainful occupations” [Id.].

II. Procedural Background

On November 13, 2020, Plaintiff filed a Complaint under ERISA for LTD “plan benefits”

(Count One) and “life insurance plan benefits” (Count Two) [Doc. 1 at 1, 8-9]. Plaintiff alleged

that Defendants’ denial of Plaintiff’s LTD and LWOP claims was “arbitrary and capricious” and

that Plaintiff “has been and continues to be disabled” under both Policies [Doc. 1 ¶¶ 37-38, 59, 64,

72]. Plaintiff specifically alleged that Defendants “reli[ed] on an unsigned form” from Dr.

Mones’s office and made a “last minute switch of labor market to Miami instead of Memphis”

[Id. ¶ 37]. Plaintiff further alleged that Defendants had “a perpetual conflict of interest” impacting

claim determinations because Defendants paid benefits out of their “own funds,” which

“influenced” their “decision-making” and incentivized “claim handlers to terminate a specified

number of claims every month,” including Plaintiff’s claims [Id. ¶¶ 42-44, 54-55].

Defendants filed a “Motion for Judgment on the Record,” [Doc. 27], asking the Court to

“dismiss Plaintiff’s claim for benefits” and “affirm” Defendants’ “determination that Plaintiff was

not eligible to receive further benefits” under both the LTD and LWOP Policies, [Docs. 27 at 1;

28 at 24]. Defendants asserted that their decision to terminate Plaintiffs’ benefits “was reasonable

and supported by the record” after an “extensive and thorough review” [Docs. 28 at 23; 47 at 2].

Plaintiff filed his own “Motion for Judgment on ERISA Record,” asserting that

Defendants’ decision to terminate his benefits was arbitrary and capricious [Doc. 33]. Plaintiff

also separately filed a supplement “to Determine Extent of Deference Given to Unum’s Decision,”

[Doc. 29], asking the Court to “give little, if any, deference to” Defendants’ decision because of

the “conflict of interest” from Defendants’ role as claims handler and benefits distributor, [id. at 1;

see also Docs. 30 at 3-4, 9-10, 12-14; 59-2 at 5-6, *sealed].

III. Standard Of Review

Under 29 U.S.C. § 1132(a)(1)(B), the Court applies either a de novo or an

arbitrary-and-capricious standard of review. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S.

101, 115 (1989); Autran v. Procter & Gamble Health & Long-Term Disability Benefit Plan, 27

F.4th 405, 411 (6th Cir. 2022). Where “the benefit plan gives the administrator or fiduciary

discretionary authority to determine eligibility for benefits or to construe the terms of the plan,”

the Court applies an arbitrary-and-capricious standard. Firestone Tire & Rubber, 489 U.S. at 115;

McCartha v. Nat’l City Corp., 419 F.3d 437, 441 (6th Cir. 2005). Here, both relevant Policies in

the Plan gave Unum the “discretionary authority to make benefit determinations under the plan,”

including “determining eligibility for benefits,” “resolving factual disputes, and interpreting and

enforcing the provisions” of each Policy [See Docs. 19-1 at 104; 19-14 at 11]. As the Parties agree,

this language confers discretion to Unum [Docs. 28 at 1; 34 at 11; 44 at 9]. The Court therefore

applies an arbitrary-and-capricious standard to review Unum’s denial of Plaintiff’s LTD and

LWOP claims. See, e.g., McCatha v. Nat’l City Corp., 419 F.3d 437, 442 (6th Cir. 2005) (applying

arbitrary-and-capricious standard of review where policy conferred the power “to construe and

interpret this Plan and each Benefit Plan and to decide all questions of eligibility”). “The burden

is on the claimant”—Plaintiff—to show that the decision of the fiduciary—Unum—“was arbitrary

and capricious.” See Lloyd v. Procter & Gamble Disability Benefit Plan, Plan #501, No. 20-4329,

2021 WL 4026683, at *5 (6th Cir. Sept. 3, 2021) (citing Farhner v. United Transp. Union

Discipline Income Prot. Program, 645 F.3d 338, 343 (6th Cir. 2011)).

Under the arbitrary-and-capricious standard, the Court upholds a plan administrator’s

decision “as long as it [wa]s the result of a deliberate, principled reasoning process.” Sandeen v.

Unum Grp. Corp., No. 22-5374, 2023 WL 2379012, at *2 (6th Cir. Mar. 7, 2023) (quoting Autran,

27 F.4th at 411); see Holden v. Unum Life Ins. Co. of Am., No. 20-6318, 2021 WL 2836624, at

*11 (6th Cir. July 8, 2021) (“[U]nder the arbitrary and capricious standard—the ‘least demanding

form of judicial review’—we ask only whether it is possible to offer an explanation for the

outcome.”). “Substantively, plan administrators may reach only those conclusions that are

supported by substantial evidence in the administrative record.” Autran, 27 F.4th at 412. The

Court considers “only the evidence available to the administrator at the time the final decision was

made.” McClain v. Eaton Corp. Disability Plan, 740 F.3d 1059, 1064 (6th Cir. 2014). And

“[p]rocedurally, plan administrators must engage in reasoned

decisionmaking.” Autran, 27 F.4th at 412.

A number of factors bear on the Court’s evaluation of the plan administrator’s decision,

including (1) the “quality and quantity of the medical evidence and the opinions on both sides of

the issues;” McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 172 (6th Cir. 2003);

(2) “whether the administrator contracted with physicians to conduct a file review as opposed to a

physical examination of the claimant;” Fura v. Fed. Exp. Corp. Long Term Disability Plan, 534

F. App’x 340, 342 (6th Cir. 2013); and (3) whether the plan administrator operated “under a

conflict of interest;” Firestone Tire & Rubber, 489 U.S. at 115. But “[n]one of the potentially

relevant factors is dispositive in its own right; [the Court] must weigh them all when deciding

whether the administrator’s ultimate conclusion resulted from a rational process.” Autran, 27 F.4th

at 412. “[T]he ultimate issue in an ERISA denial of benefits case is not whether discrete acts by

the plan administrator are arbitrary and capricious but whether its ultimate decision denying

benefits was arbitrary and capricious.” McClain, 740 F.3d at 1066 (quoting Spangler v. Lockheed

Martin Energy Sys., Inc., 313 F.3d 356, 362 (6th Cir. 2002)).

IV. Analysis

Plaintiff raised several bases that purportedly support a determination that Unum’s denial

of benefits was arbitrary and capricious. These broadly fall into three (3) categories. First,

Plaintiff challenged Unum’s medical evaluation on appeal. He specifically contended that Unum’s

decision “rest[ed] on the opinion of one in house, non-examining, file reviewing nurse, and one

non-examining file-reviewing internal medicine doctor” who “is not a specialist” in orthopedics

[Doc. 34 at 9, 15]. Plaintiff also contended that Unum “discredit[ed] the opinions” of Plaintiff’s

“treating providers and an independent physician” and did not “seek another opinion”

[Id. at 13, 16]. Second, Plaintiff challenged Unum’s “vocational analysis” both in the initial denial

of his claims and on appeal, including that Unum (1) “used the wrong residence location,”

(2) “contradicted” itself by determining that Plaintiff “did have transferrable skills” after

previously concluding he did not, and (3) provided an occupation that did not meet the gainful

occupation requirement [Id. at 16, 18-19]. Third, through his supplement and 1,027 pages of

discovery from Unum-related ERISA litigation dating back to 2004, Plaintiff alleged that a conflict

of interest involving Defendants led to the inappropriate decision to terminate his claims

[See generally Doc. 30]. The Court specifically addresses each category below but also concludes

that none of the bases within each category, viewed individually or collectively, support a

conclusion that Unum’s decision was arbitrary and capricious. The record, instead, supports

Unum’s determination that Plaintiff did not qualify as “disabled” under the Policies.

A. Unum’s Procedural And Substantive Evaluation Of The Medical Evidence

Was Reasonable.

Plaintiff focuses primarily on the medical review Unum conducted on appeal through its

in-house medical professionals. But considering the entire record, Unum’s evaluation of

Plaintiff’s appeal was reasonable and “resulted from a rational process.” See Autran, 27 F.4th at

412. Collectively, Unum’s reliance on its medical professionals’ evaluations does not weigh in

favor of finding that Unum’s decision to terminate Plaintiff’s claims was arbitrary and capricious.

i. The Policies Do Not Provide Plaintiff The Right To A Review By A

Doctor Who Specializes In Plaintiff’s Condition.

As an initial matter, Plaintiff provides no legal basis for the Court to conclude that Unum’s

employ of a board-certified doctor in internal medicine—instead of a doctor in orthopedic

medicine—to evaluate the record weighs in favor of discounting Unum’s decision to terminate

Plaintiff’s claims. Neither Policy entitles Plaintiff to review by a physician with a specific

specialty. Instead the Policies say Unum “may require you to be examined by a physician, other

medical practitioner, [and]/or vocational expert of our choice” [Docs. 19-1 at 82; 19-13 at 78].

And the Policies define “physician” as:

- a person performing tasks that are within the limits of his or her medical license;

and

- a person who is licensed to practice medicine and prescribe and administer drugs

or to perform surgery; or

- a person with a doctoral degree in Psychology (Ph.D. or Psy.D.) whose primary

practice is treating patients; or

- a person who is a legally qualified medical practitioner according to the laws and

regulations of the governing jurisdiction

[Docs. 19-1 at 97; 19-14 at 1]. On appeal, the Policies provide that Unum “will consult with a

health professional with appropriate training and experience” [Docs. 19-1 at 102; 19-14 at 9

(emphasis added)]. Plaintiff does not dispute that Dr. Schnars qualifies as a “physician” under the

Policies. Nor does Plaintiff offer any evidence to suggest that Dr. Schnars lacks “appropriate

training and experience.” See McConnell v. Nationwide Mutual Ins. Co. Benefits Administrative

Committee, No. 17-12869, 2018 WL 5306641, at *2 (E.D. Mich. Sept. 10, 2018) (holding that

review of benefits claim for a PTSD disability by a board-certified doctor in neurological

medicine—as opposed to psychiatric medicine—under a policy permitting review by “a health

care professional with appropriate expertise in the medical field” was not arbitrary and capricious).

Unum’s reliance on the opinion of a physician who is board-certified in internal medicine does not

support a finding that Unum’s denial of Plaintiff’s claims was arbitrary and capricious.

ii. Unum Had A Reasoned Explanation To Reject The Opinions Of Drs.

Dalal, Jarolem, And Mones.

“Generally, when a plan administrator chooses to rely upon the medical opinion of one

doctor over that of another in determining whether a claimant is entitled to ERISA benefits, the

plan administrator’s decision cannot be said to have been arbitrary and capricious because it would

be possible to offer a reasoned explanation, based upon the evidence, for the plan administrator’s

decision.” Evans v. UnumProvident Corp., 434 F.3d 866, 877 (6th Cir. 2006) (citation omitted).

Although a plan administrator “may not arbitrarily refuse to credit a claimant’s reliable evidence,

including the opinions of a treating physician,” “courts have no warrant to require administrators

automatically to accord special weight to the opinions of a claimant’s physician” or “impose on

plan administrators a discrete burden of explanation when they credit reliable evidence that

conflicts with a treating physician’s evaluation.” Black & Decker Disability Plan v. Nord, 538

U.S. 822, 834 (2003). When a plan administrator disagrees with the opinions of a treating

physician, it must, however, “give reasons for adopting an alternative opinion.” Elliott v. Metro.

Life Ins. Co., 473 F.3d 613, 620 (6th Cir. 2006).

Here, Unum’s decision to rely on the medical opinions of Dr. Schnars and Registered Nurse

Tirabassi over those of Plaintiff’s treating physicians was “based upon the evidence” and “a

reasoned explanation.” See Evans, 434 F.3d at 877. Neither Dr. Schnars nor Nurse Tirabassi

engaged in an impermissible “selective review of the administrative record.” See Metro. Life Ins.

Co. v. Conger, 474 F.3d 258, 265 (6th Cir. 2007) (quoting Moon v. Unum Provident Corp., 405

F.3d 373, 381 (6th Cir. 2005)) (determining that a plan administrator’s decision that “focused on

slivers of information that could be read to support a denial of coverage and ignored—without

explanation—a wealth of evidence that directly contradicted its basis for denying coverage” was

arbitrary and capricious). Instead, both medical professionals comprehensively reviewed both the

initial claims file, which included Dr. Dalal’s 2014 IME, and new information and restrictions

received on appeal from Dr. Mones and Dr. Jarolem.

Nurse Tirabassi “deferred” to Dr. Schnars’s opinion, but Nurse Tirabassi also

independently conducted a fulsome review of the record. She expressed concerns about the

restrictions Dr. Jarolem recommended for Plaintiff after Dr. Jarolem only saw Plaintiff twice in

2018—after Unum had denied Plaintiff benefits—and did not order any diagnostic testing. Nurse

Tirabassi also noted that Plaintiff did not participate in physical therapy, receive pain medication

for his back pain, or see any other back-pain specialists. And to the extent Plaintiff challenges

Unum’s referral of Plaintiff’s appeal to Nurse Tirabassi because of her training as a registered

nurse, that challenge is without merit. See Judge v. Metro. Life Ins. Co., 710 F.3d 651, 663 (6th

Cir. 2013) (“This court has previously upheld the decision of a plan administrator where a nurse

reviewed the medical evidence.”).

For her part, Dr. Schnars also engaged in a thorough review of the record. She, too, could

not reconcile the inconsistencies between Plaintiff’s physicians’ various recommended restrictions

throughout the years, Plaintiff’s own self-reported levels of activity, and an overall lack of recent

clinical examination of or medication for any lower-back impairment. See Holden, 2021 WL

2836624, at *12 (approving plan administrator physicians’ record review that “engaged with—

and explained their disagreement with” “contradictory reports” of treating physicians); Jackson v.

Blue Cross Blue Shield of Mich. Long Term Disability Program, 761 F. App’x 539, 545 (6th Cir.

2019) (approving plan administrator’s rejection of treating physicians’ evaluation that lacked any

“reliable, valid, and reasonably compelling evidence”); Raskin v. UNUM Provident Corp., 121 F.

App’x 96, 100 (6th Cir. 2005) (noting that plan administrator “had good reasons to discount”

treating physician’s recommendations that lacked “clinical data”). Dr. Schnars noted that Dr.

Dalal’s 2014 restriction was more than four (4) years old. Since then, Plaintiff (1) had infrequently

reported back pain to his other treating providers, (2) had not sought out or obtained clinical testing

to support his assertions of pain, and (3) often exercised by lifting weights at or exceeding Dr.

Dalal’s weight restriction. Dr. Schnars also noted flaws in Dr. Jarolem’s restriction. Specifically,

Dr. Jarolem’s five-pound (5 pound) restriction was not based on any medical or clinical testing.

See Storms v. Aetna Life Ins. Co., 156 F. App’x 756, 758-59 (6th Cir. 2005) (approving plan

administrator’s decision to discount treating physician’s opinion that “was not supported by

objective medical data, useful analysis, or the other opinions in the record”). And Plaintiff’s own

reported activity of lifting ten-to-fifteen-pound weights did not correspond with Dr. Jarolem’s

five-pound restriction. Dr. Schnars and Nurse Tirabassi “engaged with—and explained their

disagreement with” Dr. Dalal’s out-of-date restrictions and Dr. Jarolem’s unsupported restrictions.

See Holden, 2021 WL 2836624, at *12; Elliott, 473 F.3d at 620. Unum’s acceptance of its own

treating providers’ evaluation was, therefore, “supported by substantial evidence.” See Autran, 27

F.4th at 412; Evans, 434 F.3d at 877.

As it relates to Dr. Mones, the timing and extent of his various opinions is less than clear,

but the record simply does not support Plaintiff’s contention that Unum was “quick to terminate”

Plaintiff’s claims and did not “wait[] for clarification” from Dr. Mones [Doc. 44 at 9]. In its initial

review of Plaintiff’s claims, Unum contacted Dr. Mones’s office on multiple occasions, but Dr.

Mones did not respond to Unum’s requests for clarification. And on appeal, Dr. Schnars also

attempted to contact Dr. Mones to understand the bases for his new opinion. See Davis v. Hartford

Life & Accident Ins. Co., 980 F.3d 541, 548 (6th Cir. 2020) (upholding plan administrator’s

decision to not credit treating physician’s opinion that “conflicted with three other” opinions after

treating physician “failed to respond to inquiries”); Jackson, 761 F. App’x at 545 (viewing

favorably reviewing physicians’ attempt to contact treating physician to discuss claimant’s medical

history). Dr. Mones’s later-in-time, one-paragraph opinion that Plaintiff could not return to work

did not reference any supporting medical tests or clinical diagnostics. See McDonald, 347 F.3d at

171 (discounting supplemental report in which physician “became more definite in his opinion”

but did not re-examine claimant or receive “any new medical evidence or reports upon which to

base his clarified conclusion”). Without concrete data or other reliable evidence, it was not

arbitrary or capricious for Dr. Schnars to discount Dr. Mones’s opinion just as she discounted Dr.

Jarolem’s opinion. See Black & Decker Disability Plan, 538 U.S. at 834; Balmert v. Reliance

Standard Life Ins. Co., 601 F.3d 497, 504 (6th Cir. 2010) (finding as reasonable plan

administrator’s reliance on reviewing doctor’s evaluation that considered but rejected treating

physician’s observations and “unexplained” “apparent change” of opinion); Creech v. Unum Life

Ins. Co. v. N. Am., 162 F. App’x 445, at *8 (6th Cir. Jan. 9, 2006) (noting that treating physician’s

“failure to support his opinion with data or analysis is a sufficient reason to discount his opinion”);

Maleszewski v. Liberty Life Assur. Co. of Boston, No. 9-13926, 2010 WL 1416995, at *10 (E.D.

Mich. Apr. 8, 2010) (“[A]n opinion by a treating physician that a patient is disabled without

explanation of how the physician arrived at that determination is entitled to little weight.”).

Dr. Schnars’s consideration of Plaintiff’s existing medical record, activity levels, and

limited reference to chronic pain in the months leading up to the denial of his claims, and the SSA

ALJ’s denial of benefits under the Social Security Act renders her evaluation even more

reasonable. See Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299, 312 (6th Cir. 2010)

(upholding denial of disability benefits despite “some contradictory evidence” where the Social

Security Administration also denied benefits under the Social Security Act). On this record, Unum

had a reason to discount the medical opinions of Drs. Dalal, Jarolem, and Mones and rely on the

opinions of Dr. Schnars and Nurse Tirabassi, which were supported by substantial

evidence. See Autran, 27 F.4th at 415.

iii. Under The Circumstances Present Here, Unum’s Decision To Forgo

An Independent Medical And In-Person Evaluation Was Permissible.

Unum’s election to forgo an in-person or independent medical evaluation of Plaintiff also

fails to suggest that the denial of Plaintiff’s claims was arbitrary and capricious. “[A] file review

by a qualified physician in the context of a benefits determination” is not “inherently

objectionable.” Calvert v. Firstar Fin., Inc., 409 F.3d 286, 296 (6th Cir. 2005). But “[a] plan’s

decision to conduct a file-only review—‘especially where the right to [conduct a physical

examination] is specifically reserved in the plan—may, in some cases, raise questions about the

thoroughness and accuracy of the benefits determination.’” Elliott v. Metro. Life Ins. Co., 473

F.3d 613, 621 (6th Cir. 2006) (quoting Calvert, 409 F.3d at 296). Here, both Policies provide that

Defendants (1) may require a claimant “to be examined by a physician [or] other medical

practitioner” and (2) “can require an examination as often as it is reasonable to do so”

[Docs. 19-1 at 82; 19-13 at 78]. But “there is nothing in the plan language that expressly bars a

file review by a physician in lieu of such a physical exam.” See Calvert, 409 F.3d at 295.

Defendants’ decision to conduct a file-only review of Plaintiff’s claims does not, on its own, lead

to the conclusion that denying Plaintiff’s claims was not thorough or accurate. See id.

Nor did Dr. Schnars’s file-only review involve an impermissible credibility determination.

A plan administrator’s decision not to conduct an independent medical evaluation may be arbitrary

and capricious if “the file reviewer concludes that the claimant is not credible without having

actually examined him or her.” See Judge, 710 F.3d at 663; Bennett v. Kemper Nat. Servs., Inc.,

514 F.3d 547, 555 (6th Cir. 2008) (concluding reviewing physician made a credibility

determination by dismissing claimant’s assertions of pain as “exaggerati[on]” and

“embellish[ment]”). Dr. Schnars expressly referenced Plaintiff’s continued assertions of lower

back pain, but she noted that the medical records did not support those assertions. See Holden,

2021 WL 2836624, at *13 (rejecting contention that plan administrator made credibility

determinations when it “appears to have based its decision by crediting [claimant’s] own

statements”). She did not dismiss Plaintiff’s complaints outright. Compare Judge, 710 F.3d at

663 (holding that plan administrator did not act arbitrarily or capriciously in conducting a file-only

review where reviewers “made no credibility determinations,” “not[ed] where the reports lack[ed]

objective medical evidence,” and “point[ed] out the internal inconsistencies”), and Bell v.

Ameritech Sickness & Accident Disability Benefit Plan, 399 F. App’x 991, 1000 (6th Cir. 2010)

(“[N]either the Plan nor the [reviewing] doctors rendered credibility determinations . . . they simply

determined that the objective medical documentation in the record did not, on its own, support a

finding of disability. This was not improper or arbitrary, but rather was consistent with the Plan’s

definition of disability.”), with Bennett, 514 F.3d at 555. To be sure, Plaintiff’s lower back pain is

of a type that “is not easily subject to objective verification.” See Shaw v. AT & T Umbrella Ben.

Plan No. 1, 795 F.3d 585, 550 (6th Cir. 2015). Even so, “an award of disability for back pain

should be based on objective medical evidence rather than on the claimant’s subjective

complaints.” Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157, 171 (6th Cir. 2007). For the reasons

previously discussed, the objective medical record—which did not include a request or

recommendation for pain medication or indicate that Plaintiff was attending the recommended

physical therapy—and Plaintiff’s own reported activities simply did not support the proposed

restrictions of Plaintiff’s physicians. See Judge, 710 F.3d at 663.

Unum’s election to not physically examine Plaintiff is all the more reasonable because

under the Policies, the claimant has the burden to submit “proof of continuing disability” and

“proper proof that you remain disabled” [See Docs. 19-1 at 87; 19-13 at 77]. See Filthaut v. AT&T

Midwest Disability Benefit Plan, 710 F. App’x 676, 685 (6th Cir. 2017). On this record, Unum’s

decision to forgo conducting an independent medical evaluation of Plaintiff does not weigh in

favor of a finding that Unum’s ultimate decision to terminate Plaintiff’s claims was arbitrary and

capricious.

B. Unum’s Vocational Analysis Was Not Flawed.

Plaintiff also finds fault with Unum’s vocational analysis, specifically its (1) use of the

Miami job market, (2) conclusion that Plaintiff had transferrable skills, and (3) inclusion of an

occupation that did not meet the gainful occupation requirement. But each of these purported

“errors” fails to weigh in favor of a conclusion that Unum’s procedural evaluation of Plaintiff’s

claims was arbitrary and capricious.

First, the record supports Unum’s use of the Miami job market. Plaintiff (1) spent time in

Miami beginning in 2012, (2) saw several physicians in Miami over the years, (3) had his mail

directed to Miami, and (4) self-reported to Unum on September 22, 2017 that he lived in Miami.

After the September 22, 2017 call, Unum’s disability benefit specialist inquired whether Plaintiff

would have skills that could transfer to less physically demanding occupations “in Miami, FL at

the time/current” to evaluate potential gainful occupations for which Plaintiff would be

“reasonably fitted by education, training, or experience” [See Docs. 19-4 at 103; 19-1 at 82 (LTD

Policy); 19-13 at 77 (LWOP Policy)]. The vocational analysis conducted as part of Unum’s Fall

2017 review used Plaintiff’s self-reported location—Miami, Florida. Unum’s decision to use

Miami as the current market for Plaintiff’s claims was not, as Plaintiff contends, “improper and

self-serving” [Doc. 34 at 18]. Instead, the decision was based on the information Plaintiff, himself,

provided to Unum. And Unum had no reason to question the veracity of Plaintiff’s statement

regarding his residence. Unum’s decision to evaluate the Miami job market, therefore, “resulted

from a rational process.” See Autran, 27 F.4th at 412.

Second, Plaintiff inaccurately claims that Unum “contradict[s]” itself by determining that

Plaintiff had skills for gainful occupations for which he was “reasonably fitted by education,

training or experience” in 2017 “based on the same occupational information” from 2014

[Doc. 44 at 13]. Unum conducted a skills assessment for Plaintiff in August of 2014 based on

“Sedentary or Light physical demand levels” “in Memphis, TN” [Doc. 19-2 at 188]. That

assessment concluded it was “unlikely” that Plaintiff “would have sufficient skills for gainful

alternate occupations within the Sedentary or Light physical demand levels as defined by eDOT”

[Doc. 19-2 at 188 (emphasis added)]. The assessment did not evaluate Plaintiff’s “transferrable”

skills [Id.]. Unum’s VRC Parras-Potenzo conducted an additional skills assessment in May 2016

[Doc. 19-3 at 42]. She concluded that Plaintiff “would have skills for less physically demanding

occupations” but “th[o]se occupations would not provide a gainful [occupation] wage” “in

Memphis, TN” [Id.]. Plaintiff’s changed circumstances in September 2017 impacted Unum’s third

skills assessment. By that time, the SSA ALJ determined that Plaintiff could engage in work at

the “light occupational base” [Doc. 19-4 at 81 (emphasis added)]. And Plaintiff had self-reported

that he lived in downtown Miami. Parras-Potenzo reviewed (1) “all occupational and vocational

evidence provided,” “including analysis of current limitations and restrictions by medical and

clinical personnel,” and (2) Plaintiff’s past employment history, including his certifications, to

conclude that Plaintiff “had demonstrated skills/competencies” in seven (7) core competencies

[Id.]. Based on this information, she concluded that Plaintiff “would have skills for alternate

occupations which are performed with occasional lifting up to 20 pounds, frequently up to 10

pends; frequent sitting with occasional standing, walking with ability to make positional” changes

[Id. at 105-06]. Unum’s determination that Plaintiff had transferrable skills reflects the reality of

Plaintiff’s changed capacity and job market.

Third, Unum’s inclusion of an occupation that did not meet the gainful occupation

requirement does not render the otherwise thorough vocational analysis fatally flawed or change

the outcome. Plaintiff faults Unum’s use of the “Security Guard” occupational title with a median

hourly wage of $13.57, which falls below the calculated gainful occupation wage of $13.68

[See Doc. 19-12 at 116]. Unum specifically noted in its Appeal Decision that “[t]he occupation of

Security Guard is gainful” under the LWOP Policy but not the LTD Policy [Id.]. But the inclusion

of this position does not render the entire decision to deny Plaintiff’s claims arbitrary and

capricious. The Policies defined “disabled” as when “you are unable to perform the duties of any

gainful occupation” [Docs. 19-1 at 82; Doc. 19-13 at 76-77, 100 (emphasis added)]. The two (2)

other alternate occupational titles—Inspector Component Parts and Final Inspector—had income

exceeding the gainful occupation wage. With at least one gainful occupation included in the denial

letter—satisfying the requirements of the Policies—Unum’s vocational analysis was the product

of “reasoned decisionmaking.” See Autran, 27 F.4th at 412.

C. Defendants’ Conflict Of Interest Does Not Weigh In Favor Of A Conclusion

That The Decision To Terminate Plaintiff’s Benefits Was Arbitrary And

Capricious.

If a plan administrator operates “under a conflict of interest, th[e] conflict must be weighed

as a ‘facto[r] in determining whether there is an abuse of discretion.’” Firestone Tire & Rubber,

489 U.S. at 115 (quoting Restatement (Second) of Trusts § 187 cmt. d (1959)). “[T]he fact that a

plan administrator both evaluates claims for benefits and pays benefits claims” creates a conflict

of interest. See Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 112 (2008); see also Rothe v. Duke

Energy Long Term Disability Plan, 688 F. App’x 316, 319 (6th Cir. 2017). The use of “in-house

consultants” who could “have an incentive to make a finding of ‘not disabled’ in order to save

their employers money and preserve their own consulting arrangements” may also create a conflict

of interest. See Black & Decker, 538 U.S. at 832.

But conflicts of interest “prove less important (perhaps to the vanishing point) where the

administrator has taken active steps to reduce potential bias and to promote accuracy, for example,

by walling off claims administrators from those interested in firm finances, or by imposing

management checks that penalize inaccurate decisionmaking irrespective of whom the inaccuracy

benefits.” Id. at 117. Ultimately, the Court gives “more weight to the conflict in circumstances

that suggest a higher likelihood that [the conflict] affected the benefits decision.” Rothe, 688 F.

App’x at 319. But “[m]ere allegations of the existence of a structural conflict of interest are not

enough to show that the denial of a claim was arbitrary; there must be some evidence that the

alleged conflict of interest affected the plan administrator’s decision to deny benefits.” Jackson v.

Metro. Life, 24 F. App’x 290, 292 (6th Cir. 2001). Plaintiff must “provide ‘significant evidence’

that the conflict actually affected or motivated the decision at issue.” Cooper, 486 F.3d at 165

(quoting Peruzzi v. Summa Med. Plan, 137 F.3d 431, 433 (6th Cir. 1998)). Conjecture is not

enough. See id.

Plaintiff has not provided significant evidence that the use of in-house medical professional

reviewers affected Unum’s decision to terminate Plaintiff’s benefits. Plaintiff’s discussion of

former in-house physicians’ “bonuses” in other cases does not shed light on the benefits decision

in this case. Plaintiff specifically takes issue with Dr. Schnars. But Plaintiff has not showed that

Dr. Schnars was biased in reviewing Plaintiff’s claim or received any “bonus” for recommending

that Unum deny Plaintiff’s appeal. Compare DeLisle v. Sun Life Assur. Co. of Can., 558 F.3d 440,

445 (6th Cir. 2009) (giving “more weight” to a conflict presented by file reviewers “under regular

contract” with defendants where plaintiff provided evidence that reviewers received “incomplete

and potentially prejudiced information” that “portray[ed] the claimant in a negative light”), and

Evans, 434 F.3d at 880 (finding “significant evidence” of a conflict where “a series of inter-office

e-mails and memos” between reviewers suggesting “a predisposition toward terminating”), with

Kalish v. Liberty Mutual/Liberty Life Assur. Co. of Boston, 419 F.3d 501, 507 (6th Cir. 2008)

(refusing to discount in-house reviewer’s medical opinion where plaintiff “offered only conclusory

allegations of bias,” “failed to present any statistical evidence” to show reviewer “consistently

opined that claimants are not disabled,” and provided “no evidence” that defendants “attempted to

tamper with or inappropriately influence” reviewer). Without evidence, Plaintiff cannot show that

this conflict affected Defendants’ decision here. See Cooper, 486 F.3d at 165; Cook v. Prudential

Ins. Co. of Am., 494 F. App’x 599, at *5 (6th Cir. Aug. 16, 2012) (rejecting contention of bias

supported by “no more than cursory statements”).

Plaintiff states that “Courts have repeatedly found” Dr. Schnars’s “opinions to be not

worthy of giving weight” [Doc. 64 at 4]. Significant evidence of a conflict may arise from

“evidence that the consulting physician’s (i.e., the reviewing physician’s) ‘conclusions have been

questioned in at least three federal cases,’ with those prior courts noting, for example, that the

reviewing physician’s language ‘appears deliberately ambiguous and vague.’” Holden, 2021 WL

2836624, at 17 n.21 (quoting Elliot, 473 F.3d at 620). Plaintiff references opinions from five (5)

federal courts that have “overturned Unum’s decision, which was based on Dr. Schnar’s [sic]

medical opinion” [Doc. 64 at 4]. But a substantive review of those opinions—several of which

involved de novo review—does not suggest that those courts each specifically questioned Dr.

Schnars’s conclusions. Only one case specifically addressed Dr. Schnars’s “brief opinion” that

contained a “handful of sentences.” See Anderson-Posey v. Unum Life Ins. Co. of Am.,

237 F. Supp. 3d 1144, 1155 (N.D. Okla. 2017) (applying an arbitrary-and-capricious standard of

review). For the reasons previously discussed, Dr. Schnars’s review in the case before this Court

was thorough—Dr. Schnars considered Plaintiff’s occupational duties, medical records, and report

of pain.

Additionally, Plaintiff has not presented concrete evidence suggesting that Defendants’

business structure affected its decision here. To be sure, Defendants’ role as plan administrator

and payor of any benefits creates a conflict of interest. See Metro. Life Ins., 554 U.S. at 112. But

as an initial matter, Plaintiff has not meaningfully connected his general reference to Defendants’

“corporate practice” of “closure quotas” “in the late 1990s through the early 2000s” that allegedly

“has not changed” to this case [See Doc. 30 at 3, 8]. See Frost v. Unum Life Ins. Co. of Am., No.

21-CV-269, 2023 WL 2261415, at *18 (E.D. Tenn. Feb. 14, 2023) (rejecting “1,000 pages of

evidence of purported bias” because most “relates to events that took place as many as 15 years

before [the plaintiff’s] claim was submitted”). To the extent that Plaintiff does provide evidence

of a conflict here, there is no “significant evidence” that the conflict infiltrated Defendants’

decision in this case. See Cooper, 486 F.3d at 165.

Plaintiff focuses on Director Ridlon’s knowledge of financial weekly tracking reports

provided by Unum’s financial department. But any connection between Ridlon’s “pattern of

consistently meeting or exceeding the recovery plan” and speculative pressure Ridlon felt to

terminate Plaintiff’s claims is tenuous at best. The record reflects that Ridlon had little

involvement in the overall evaluation of Plaintiff’s claims. The involvement that Ridlon did have

occurred while Defendants paid Plaintiff benefits and transferred his case for “ongoing handling”

in 2016 [See Docs. 19-2 at 29-30; 19-4 at 29-30, 61]. Ridlon did not approve the denial of

Plaintiff’s claims [Doc. 19-4 at 185-86]. The favorable treatment Plaintiff received over several

years while Ridlon oversaw Plaintiff’s claims belies the suggestion of Ridlon’s improper bias. See

Sandeen v. Paul Revere Life Ins. Co., No. 18-CV-248, 2022 WL 966848, at *14-15 (E.D. Tenn.

Mar. 30, 2022) (holding that financially-based conflict of interest did not “heavily influence[] the

decision to deny” benefit claims where defendants “made decisions beneficial to” plaintiff), aff’d

sub nom. Sandeen, 2023 WL 2379012. What is more, Plaintiff does not suggest, and the record

does not reflect, that any of the disability benefit specialists, vocational rehabilitation consultants,

or medical reviewers who thoroughly evaluated Plaintiff’s claims and appeal over a period of years

had any access to the financial weekly tracking reports. See Schwalm, 626 F.3d at 312 (concluding

plan administrator and payor “thorough[ly] review[ed] the record” such that there was “no

indication that the review was improperly influenced by the inherent conflict of interest). On this

record, the Court cannot conclude that Defendants’ structural conflict of interest affected its

decision to deny Plaintiff’s claims or otherwise weighs in favor of a conclusion that Defendants’

denial of Plaintiff’s claims was arbitrary and capricious.

V. Conclusion

Defendants’ decision to deny Plaintiff’s claims for LTD and LWOP benefits resulted from

“a deliberate, principled reasoning process” and was “supported by substantial evidence.”

Sandeen, 2023 WL 2379012, at *2. That decision, therefore, was not arbitrary and capricious.

Accordingly, the Court GRANTS Defendants’ “Motion for Judgment on the Record” [Doc. 27]

and DENIES Plaintiff’s “Motion for Judgment on ERISA Record” [Doc. 33]. This case is

dismissed. An appropriate judgment shall enter.

IT IS SO ORDERED.

s/ Katherine A. Crytzer

KATHERINE A. CRYTZER

United States District Judge