Daniel Collins v. Unum Life Ins. Co. of America
682 F. App'x 381
| 6th Cir. | 2017Background
- Daniel Collins, an Affymetrix employee with long-standing poorly controlled type 2 diabetes, slipped in his employer’s parking lot on Jan 6, 2012, suffering a trimalleolar ankle fracture; his foot was amputated on Feb 8, 2013.
- Treating clinicians repeatedly diagnosed diabetes, diabetic neuropathy/Charcot neuroarthropathy, and chronic osteomyelitis in the records leading up to and after the amputation.
- Collins sought accidental-loss benefits under an ERISA plan administered and funded by Unum; the plan excluded losses "caused by, contributed to by, or resulting from . . . disease of the body."
- Unum medical reviewers (Drs. Sweeney and Golder) concluded diabetes likely contributed to the Charcot development, infection risk, and treatment failure, and thus denied benefits; a treating physician (Dr. Berkowitz) circled “No” to whether disease contributed but gave no explanatory analysis.
- Collins sued under 29 U.S.C. § 1132(a)(1)(B); the district court applied arbitrary-and-capricious review, denied extra discovery, and upheld Unum’s denial. The Sixth Circuit affirmed.
Issues
| Issue | Collins' Argument | Unum's Argument | Held |
|---|---|---|---|
| Whether Unum’s denial of accidental-loss benefits was arbitrary and capricious under the Plan’s disease exclusion | Collins: amputation was caused only by the fracture/infection, not by disease; treating physician said disease did not contribute | Unum: medical record and reviewers show diabetes/neuropathy/Charcot and osteomyelitis contributed to the loss | Held: Denial upheld — substantial evidence supports that diabetes contributed, so exclusion applies |
| Effect of Unum’s conflict of interest (administrator-payor) on review | Collins: conflict warrants extra scrutiny and discovery | Unum: conflict is a factor but not dispositive; decision supported by record | Held: Conflict considered but does not overturn denial; Collins offered only general allegations of bias |
| Adequacy of Unum’s medical review and weight to treating physician | Collins: Dr. Golder failed to review entire record and ignored treating physician’s contrary view | Unum: reviewer considered records and reasonably discounted the treating physician’s conclusory notation | Held: Review adequate; treating physician’s conclusory “no” lacked analysis and could be discounted |
| Whether Unum’s failure to perform a physical exam rendered the denial unreasonable | Collins: absence of exam (and denial to conduct discovery) compromised accuracy, citing Calvert | Unum: plan did not reserve a right to exam; post-amputation exam unlikely to clarify contributing pre-amputation causes | Held: No requirement to examine; failure to examine did not make decision arbitrary and capricious |
Key Cases Cited
- McCartha v. Nat’l City Corp., 419 F.3d 437 (6th Cir.) (burden on administrator to prove plan exclusion applies)
- Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299 (6th Cir. 2010) (arbitrary-and-capricious review requires assessing quality and quantity of medical evidence)
- Glenn v. MetLife, 461 F.3d 660 (6th Cir. 2006) (consider medical-opinion quality; conflict of interest is a factor)
- Glenn v. MetLife, 554 U.S. 105 (2008) (administrator-payor conflict is a factor in arbitrary-and-capricious review; may be a tiebreaker)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (administrator need not give special weight to treating physician)
- Calvert v. Firstar Finance, Inc., 409 F.3d 286 (6th Cir. 2005) (file-review may be acceptable, but failure to examine and failure to address controlling evidence can render denial unreasonable)
- Baker v. United Mine Workers of Am. Health & Ret. Funds, 929 F.2d 1140 (6th Cir.) (standard for upholding admin decision: deliberate principled reasoning supported by substantial evidence)