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Eleventh Circuit finds Denial of Disability Benefits to be Arbitrary and Capricious

Posted by Marissa A. Hornsby | Jul 08, 2022 | 0 Comments

Sonja Sisung was a hospital pharmacist for Emory Healthcare, Inc.  She suffered a spinal injury in a fall at work, leaving her in significant pain.  Unum, which insures Ms. Sisung's employer-sponsored ERISA disability plan, granted Ms. Sisung long-term disability benefits for two years, after which time Ms. Sisung was required to prove that she was disabled such that she could not perform “any gainful occupation” for which she is reasonable fitted. 

Ms. Sisung continued to experience pain from her spinal injury and significant cognitive side effects from her prescribed gabapentin pain medication.  Most of Ms. Sisung's treating medical providers supported work restrictions.  However, Unum's in-house reviewers concluded that Sisung could perform certain sedentary work based on a file review and her neurologist's nurse practitioner's phone statement to Unum that she could perform sedentary office work.  As a result, Unum denied Ms. Sisung's continued disability benefits.  Ms. Sisung appealed and submitted a functional capacity (“FCE”) report and neuropsychological evaluation in support of her disability claim.  Ms. Sisung's neuropsychological evaluation made clear that she had significant cognitive impairments as a side effect of her pain medication which would prevent her from working.  After her appeal was denied, Ms. Sisung filed suit.  The district court found that Unum's decision was not arbitrary and capricious.

The Eleventh Circuit disagreed, finding that Unum's denial was both de novo wrong and unreasonable.  The court found that although there was adequate evidence for Unum to conclude that Ms. Sisung had the physical capacity to perform sedentary work, there was no reasonable basis to conclude that she had the cognitive ability to work.  Her neuropsychological evaluation indicated cognitive impairments upon which Unum did not obtain a second opinion.  Unum's own reviewing neurologist never disagreed with the conclusion that if Ms. Sisung's neuropsychological evaluation was accurate, then her cognitive impairments that would prevent her from working in her field.  Instead, Unum's neurologist used questionable reasoning to discard all of the results of the evaluation.  Ultimately, the Court found there was no reasonable basis for Unum to disregard these test results nor to conclude that Ms. Sisung's activity level demonstrates cognitive capacity consistent with an ability to work.

The Eleventh Circuit thus reversed and remanded the case to the district court to determine benefits due and attorneys' fees.

About the Author

Marissa A. Hornsby

Marissa is an Associate Attorney in Pridgen Bassett's law practice. Marissa advises and represents clients across a diverse range of industries. She provides thoughtful and efficient representation to businesses, executives, and individuals in a variety of employment-relate...

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