Goodman v. First Unum Life Ins. Co.

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TANYA GOODMAN, Plaintiff, v. FIRST UNUM LIFE INSURANCE COMPANY and UNUM GROUP, Defendants.

No. 2:21-cv-00902-BJR

United States District Court, W.D. Washington, Seattle

May 3, 2023

ORDER GRANTING IN PART PLAINTIFF TANYA GOODMAN'S MOTION FOR JUDGMENT ON THE RECORD

Barbara Jacobs Rothstein United States District Judge

This matter comes before the Court on the cross-motions for judgment on the record under Federal Rule of Civil Procedure 52 by Defendants First Unum Life Insurance Company and Unum Group (collectively, “Unum”), Dkt. No. 31, and Plaintiff Tanya Goodman, Dkt. No. 33, and on Goodman's motion to supplement the record. Dkt. No. 34. The Court GRANTS IN PART Goodman's motion for judgment on the record, GRANTS her motion to supplement the record, and DENIES IN PART Unum's motion for judgment on the record. The Court hereby REMANDS the matter to Unum to determine whether Goodman can “perform the duties of any gainful occupation for which [she is] reasonably fitted by education training or experience,” pursuant to the relevant benefit plan. Dkt No. 18-11 at 16.

BACKGROUND

Goodman claims that Section 502(a)(1)(B) of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)(B) warrants judgment against Unum for failure to pay her disability insurance benefits to which she was entitled under her employer's benefit plan (“the Plan”). Dkt. No. 1 at 4. Goodman also claims that Unum violated the terms of the Plan and seeks an injunction under 29 U.S.C. § 1132(a)(3) “compelling Unum to correct its claims-handling policies, practices, training, and procedures, together with any other declaratory or equitable relief the Court deems appropriate.” Dkt. No. 1 at 5.

“Under ERISA, the proper standard of review of a plan administrator's benefits denial is de novo unless the plan grants discretionary authority to the administrator.” Mirick v. Prudential Ins. Co. of Am., 100 F.Supp.3d 1094, 1096 (W.D. Wash. 2015) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). The parties have stipulated to de novo review. Dkt. No. 13 at 2. The court accepts the parties' stipulation, see Rorabaugh v. Cont'l Cas. Co., 321 Fed.Appx. 708, 709 (9th Cir. 2009), conducts a trial of this matter under Rule 52 based on the administrative record considered by Unum, and issues the findings of fact and conclusions of law as set forth below.

GOODMAN'S MOTION TO SUPPLEMENT THE RECORD

As an initial matter, the Court addresses Goodman's motion to supplement the administrative record to add a June 24, 2022 decision by an administrative law judge (“ALJ”) at the Social Security Administration (“SSA”), granting her Social Security disability benefits. Dkt. No. 34 at 1; see Dkt. No. 34-4 (2022 SSA decision). The Court has discretion to expand the record where “additional evidence is necessary to conduct an adequate de novo review of the benefit decision.” Mongeluzo v. Baxter Travenol Long Term Disability Benefit Plan, 46 F.3d 938, 944 (9th Cir. 1995); see also Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094 (9th Cir. 1999). The following circumstances should be considered when deciding whether supplementing the administrative record is necessary:

[C]laims that require consideration of complex medical questions or issues regarding the credibility of medical experts; the availability of very limited administrative review procedures with little or no evidentiary record; the necessity of evidence regarding interpretation of the terms of the plan rather than specific historical facts; instances where the payor and the administrator are the same entity and the court is concerned about impartiality; claims which would have been insurance contract claims prior to ERISA; and circumstances in which there is additional evidence that the claimant could not have presented in the administrative process.

Opeta v. Northwest Airlines Pension Plan for Cont. Emps., 484 F.3d 1211, 1217 (9th Cir. 2007) (citation omitted).

The Opeta factors support expanding the record to include the 2022 SSA decision. The SSA's prior decision in 2020 already forms part of the administrative record, Dkt. No. 17-6 at 3851, and the 2022 SSA decision results from this Court's decision reversing and remanding the 2020 decision. See Tanya G. v. Comm'r of Social Security, C21-0530-SKV, 2022 WL 35494, at *1 (W.D. Wash. Jan. 3, 2022). The 2022 SSA decision was issued after the administrative record was filed, so it could not have been included in it. And this case certainly requires consideration of complex medical questions and issues regarding the credibility of medical experts, which are matters that the 2022 SSA decision speaks to. In light of the record and circumstances in this case, the Court grants Goodman's motion to supplement the record with the 2022 SSA decision. Dkt. No. 34-4.

The Court next turns to the parties' cross-motions for judgment on the record.

FINDINGS OF FACT

A. Goodman's Employment and the Terms of Coverage Provided Under the Plan

(1) Goodman worked as a Vice President Group Account Director for Aegis Media Americas, Inc.'s iProspect division. Dkt. No. 16-10 at 24, 27. She held an executive leadership role where she was responsible for the strategic management of clients' digital marketing programs and managed a $6,000,000 revenue stream. Dkt. No. 16-7 at 39; Dkt. No. 16-19 at 5. She handled accounts for companies such as T-Mobile and led a team of 20 employees. Dkt. No. 16-6 at 1; Dkt. No. 16-7 at 39. Before she requested disability benefits, her annual income was $202,878. Dkt. No. 18-12 at 28.

(2) Goodman participated in her employer's ERISA plan, the Aegis Media Americas, Inc. Plan. Dkt. No. 7 at 1-2; Dkt. No. 16 at 1. The Plan includes a disability insurance policy written by First Unum Life Insurance Company. Dkt. No. 18-11 at 1-42. Goodman was covered under the Plan's short-term disability (“STD”) benefits, which are paid for up to 26 weeks. Dkt. No. 18-12 at 28; Dkt No. 18-17 at 15. Goodman was also covered under the Plan's long-term disability (“LTD”) benefits, which begin after a Plan participant's STD benefits end. Dkt. No. 18-11 at 4-5.

(3) The Plan defines disability as follows:

You are disabled when Unum determines that:

- you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and

- you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.

After 24 months of payments, you are disabled when 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.

You must be under the regular care of a physician in order to be considered disabled.

Dkt. No. 18-11 at 16 (emphasis omitted). The Plan thus identifies two different standards: one that applies up to 24 months of payments, and one that applies after 24 months of payments. Unum did not evaluate Plaintiff's disability claim under the Plan's more stringent “any gainful occupation” standard because it determined that Goodman was unable to meet the less stringent “regular occupation” standard. Dkt. No. 31 at 3 n.5. The Plan also limits the maximum benefits available for mental illness to 24 months. Dkt. No. 18-11 at 22.

(4) Unum acts as the plan administrator for deciding LTD claims. Id. at 38. The key terms in the Plan's definition of disability are defined as follows:

“Sickness” means “an illness or disease;”

“Injury” means “a bodily injury that is the direct result of an accident and not related to any other cause;”

“Limited” means “what you cannot or are unable to do;”

“Material and Substantial Duties” mean duties that “are normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified;”

“Regular Occupation” means “the occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location;”

“Mental Illness” means “a psychiatric or psychological condition classified in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), published by the American Psychiatric Association, most current as of the start of a disability. Such disorders include, but are not limited to, psychotic, emotional or behavioral disorders, or disorders relatable to stress.”

Id. at 30-32. The Plan also defined “Regular Care” as follows:

- you personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and

- you are receiving the most appropriate treatment and care which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards.

Id. at 31.

B. Goodman's Accident and Initial Treatment

(5) On January 9, 2018, Goodman was rear-ended by another vehicle while driving her son to preschool. Dkt. No. 16-3 at 49. According to her providers' reports, the accident caused her head to strike the headrest, and she thought that she may have also struck her face, although she did not recall it. Id. at 4, 49. She reported experiencing dizziness blurred vision, headache, and some ringing in her ears. Id. at 4, 49. She also believed that she may have briefly lost consciousness. Id. at 49, 62. At the time of the accident, the other vehicle was estimated to be moving at 30 miles per hour, Goodman was wearing a seatbelt, the airbags did not...