A California court found that First Unum Life Insurance Company (“Unum”) wrongly denied benefits to a bank Systems Engineer with CFS.
Background
Ms. Tam worked as a Senior Systems Engineer at a Bank in California. Although she sat most of the day, it required high levels of concentration, attention, and making decisions.
In 2017, Ms. Tam’s doctor diagnosed her with Chronic Fatigue Syndrome (“CFS”), a disease characterized by extreme and consistent fatigue, no matter how much one rests. Although she had other conditions, including depression and anxiety, she filed her claim for long-term disability (“LTD”) benefits based on CFS.
Her doctor agreed that she was unable to work, her condition had worsened as any little activity was so exhausting that she had to rest, and her cognitive function declined. The doctor’s conclusion was supported by medical records.
Unum had four of its doctors review Ms. Tam’s medical file, although none of them examined her nor had experience with CFS. They all disagreed with Ms. Tam’s doctor. Ultimately, Unum accepted its doctors’ opinions and denied Ms. Tam’s claim because there was no objective evidence to support CFS.
The Court’s Decision
The trial court disagreed with Unum’s decision to deny Ms. Tam benefits because there was no objective evidence supporting CFS.
The court found several of Unum’s actions improper. First, it was wrong to rely on the opinions of its doctors over the opinions of Ms. Tam’s own doctors. Ms. Tam’s doctors, who all examined and treated her, were more persuasive than Unum’s doctors, none of whom had any experience in CFS nor did they examine Ms. Tam.
In addition, the court also found fault with Unum’s doctors’ reports which mischaracterized, or entirely ignored, medical evidence in the records.
Lastly, the court found it was improper for Unum’s doctors to require objective evidence to support Ms. Tam’s condition. This was improper because CFS is not diagnosed with objective evidence but rather on the patient’s subjective complaints of pain and fatigue.
Based on the medical evidence present in Ms. Tam’s record, the court reversed Unum’s denial and found that she was entitled to LTD benefits.
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