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Field Technician With Back Disorder Wins Unum Disability Appeal

The case involves a 62-year-old field technician for a major mattress delivery company whose job required significant physical activity. After developing serious low back problems, he underwent lumbar fusion surgery and could no longer perform the physical demands of his occupation. Unum initially agreed that he was unable to perform his job and paid long-term disability benefits for the first 24 months. However, when the policy’s definition of disability changed from his own occupation to any occupation, Unum terminated his benefits.

Before terminating the claim, Unum had the client’s updated medical records reviewed by a nurse, a board-certified internal medicine physician, and a physical medicine physician. All three concluded that he was capable of light-duty work. Based on those reviews, Unum determined that he no longer met the policy’s definition of disability. None of the reviewers personally examined the client, despite his continued low back pain and complications following surgery.

Attorney Jason Mackri developed an appeal focused on obtaining objective evidence of the client’s actual functional abilities and documenting the continuing problems with his lumbar spine. Key components of the appeal included:

• Arranging a Functional Capacity Evaluation (FCE), which demonstrated that the client could not perform light-duty work and was unable to sustain even sedentary work because he could sit for only limited periods.
• Obtaining an updated MRI of the lumbar spine after discovering that no recent imaging had been performed.
• Using the MRI findings to document postsurgical changes and demonstrate that the client’s back had not healed as well as Unum’s medical reviewers had suggested.
• Obtaining a detailed Attending Physician Statement from the client’s treating physician clarifying that although the lumbar fusion surgery itself had gone well, the client continued to experience significant complications, restrictions, and limitations.
• Connecting the FCE, MRI findings, physician support, and medical records to establish that the client could not reliably perform light or sedentary employment.

The change in the policy’s definition of disability was central to the case. During the first 24 months, the client only needed to establish that he could not perform his own physically demanding occupation. After 24 months, however, he had to demonstrate that he could not perform any occupation for which he was reasonably qualified based on his education, training, and experience. This meant the appeal needed to establish that his limitations prevented not only heavy physical work but also light and sedentary employment. The FCE was particularly important because it documented his inability to sit for the prolonged periods generally required for sedentary work.

Mackri submitted a comprehensive appeal containing the client’s medical records, updated MRI, FCE results, physician statements, reports, and a detailed written argument addressing Unum’s reasons for terminating benefits. The complete submission totaled hundreds of pages and potentially more than 1,000 pages of evidence. Because an ERISA disability appeal may establish the administrative record used in any later lawsuit, the attorneys emphasized the importance of submitting all available medical evidence and arguments during the appeal rather than treating it as a simple request for reconsideration.

Unum ultimately reversed its decision and reinstated the client’s long-term disability benefits under the more demanding any-occupation standard. The case demonstrates that a successful surgery does not necessarily mean a claimant has regained the functional capacity required to return to work. Although a surgeon may document that a procedure went well, a claimant can continue experiencing pain, limited sitting tolerance, and other restrictions that prevent sustained employment. Objective testing such as updated imaging and an FCE can help document the difference between a successful surgical procedure and actual functional recovery.

The client’s claim continues to require ongoing management even after the successful appeal. Unum periodically reevaluates disability claims and may request updated medical records or physician statements to determine whether benefits should continue. Maintaining consistent treatment and updated documentation of the client’s restrictions and limitations is therefore important to protecting his benefits following reinstatement.