Hiller, PC is thrilled to announce its litigation victory over First Unum Life Insurance Company in the case of Macalou v. First Unum Life Insurance Company. On November 22, 2024, the Honorable P. Kevin Castel of the Southern District of New York ruled in favor of our client, awarding her over three (3) years of retroactive Long Term Disability benefits (plus future benefits), attorneys’ fees, costs, and pre-judgment interest.
Prior to her disability, the Plaintiff was an Associate Partner at a prestigious consulting firm in New York City. She began suffering from severe symptoms associated with certain psychological illnesses that prevented her from performing the duties of her own occupation. Unfortunately, First Unum denied the Plaintiff’s Long Term Disability claim and her administrative appeal even though all of her treating physicians and other consultants who examined her found her to be totally disabled. Rather than properly evaluate the medical evidence, Unum ignored the statements and conclusions reached by the Plaintiff’s treating physicians, and instead relied on its in-house file review doctors who never even spoke to, let alone examined, the Plaintiff. Despite evidence to the contrary, First Unum alleged that the Plaintiff’s symptoms improved before the end of the Elimination Period (i.e., the first 6 months of disability before LTD benefits become payable). As a result, Hiller, PC commenced a lawsuit seeking, among other things, recovery of the disability benefits to which our client was rightfully entitled by virtue of her participation in a group Long Term Disability Plan (“LTD Plan”).
During the course of litigation, Hiller, PC obtained two key preliminary victories:
First, Hiller, PC convinced the Court that the Plaintiff was entitled to certain conflict of interest discovery. In ERISA Long Term Disability cases, an insurance company that both pays LTD benefits and administers the claim is presumed to have a conflict of interest, which could entitle the Plaintiff to discovery shedding light on the significance of that conflict. Here, following a letter motion filed by Hiller, PC, the Court required that First Unum produce: (a) bonus, commission, stock option, or financial incentives received by First Unum’s in-house doctor and in-house vocational consultants who reviewed the Plaintiff’s claim; (b) the performance reviews from First Unum’s in-house medical and vocational consultants; (c) information regarding any reserve, recovery plan, or recovery target relating to the Plaintiff’s Claim; and (d) any internal rules, procedures, manuals or guidelines governing the adjudication of LTD benefit claims and administrative appeals.
Second, Hiller, PC obtained de novo review. In ERISA Long Term Disability cases in New York, the Court reviews claims under one of two standards of review – de novo or arbitrary and capricious. A de novo review is more favorable for disability claimants because, rather than determine whether First Unum’s determinations were reasonable (as under the arbitrary and capricious standard of review), the Court must carefully review the record and decided for itself whether the Plaintiff is totally disabled as defined by the LTD Plan. Here, after being forced to file two (2) separate pre-motion letters seeking permission to file a motion for partial summary judgment on the standard of review, Unum conceded that the Plaintiff’s case was subject to a more beneficial de novo review. In a stipulation “so ordered” by the Court, First Unum acknowledged that Plaintiff’s claim must be reviewed de novo because First Unum failed to meet the timeline requirements set forth in the ERISA Claims Procedure Regulations.
With de novo review firmly in place, the parties submitted their respective Trial Briefs for Judge Castel’s consideration. Following his review and analysis, Judge Castel issued a 43-page decision ruling in the Plaintiff’s favor on all of her claims and finding that her psychological symptoms prevented her from performing the duties of her own occupation as an Associate Partner. Consequently, the Court ruled that she was entitled to LTD benefits. Judge Castel agreed with Hiller, PC’s arguments that:
- The length and nature of the Plaintiff’s relationships with her treating physicians “renders their opinions more credible and persuasive than those of First Unum’s file reviewers;”
- “Affording greater weight to the opinions of treating physicians [who actually examined the Plaintiff] is especially appropriate where, as here, a plaintiff’s symptoms are subjective and arise from psychiatric conditions;”
- The conclusions reached by the Plaintiff’s treating physicians are entitled to greater weight than First Unum’s file reviewers because they are consistent with one another;
- The conclusions of the Plaintiff’s treating physicians were supported by neuropsychological testing – i.e., objective medical information which “is a valuable source of corroborating evidence;”
- First Unum’s two nurse consultants do not have relevant expertise to opine on the Plaintiff’s health conditions. As a result, their opinions are less persuasive; and
- Plaintiff’s subjective complaints of disabling conditions must be considered. The Court, citing to precedent stated that subjective complaints “are not merely evidence of a disability, but are an important factor to be considered in determining disability.”
Based on these conclusions of
law (among others), the Court determined that the Plaintiff proved by a preponderance of the evidence that she has been disabled since day one of her disability. Judge Castel then went a step further finding that the Plaintiff’s “success on the merits” entitles her to attorneys’ fees, costs, and pre-judgment interest.
The results of this case underscore the importance – not only of fighting for Long Term Disability benefits – but of hiring an attorney well versed in ERISA Long Term Disability law. The attorneys at Hiller, PC have over 50 years of experience representing policyholders in their fight against insurance companies.
For a free case evaluation, contact the disability insurance lawyers at Hiller, PC at (212) 319-4000 or info@hillerpc.com.
