Our client, “Sue”, received good news today when Unum was ordered to pay her long-term disability (“LTD”) benefits all the way back to August 2008. The Seventh Circuit Court of Appeals, which reviews LTD denials against claimants in Wisconsin, Indiana and Illinois, decided today that Unum is arbitrary and capricious for two reasons. First, it is clear that Sue does not “have reliable, sustainable functional capacity at any level of physical demand”. Indeed, Sue’s treating rheumatologist concludes that “[d]espite interventions by neurology, psychiatry, psychology, neuropsychology, orthopedics, physiatry, integrative medicine, [and a] pain program with multiple interventions from these services, [Sue] remains unable to work.” After a review of the record, “we agree that the record evidence points to a finding of disability under the ‘any occupation’ standard,” said the Court.
The second basis for the Court’s decision is that Unum denied benefits because Sue’s symptoms are “self-reported”, even though the Summary Plan Description (“SPD”), a document which explains the LTD benefit entitlement to employees like Sue, does not include a self-reported symptoms clause. The SPD clearly sets out that long-term benefits will be discontinued after twenty-four months if a participant’s disability is due to mental illness or substance abuse. It does not, however, mention that this same time limitation applied if a participant’s disability is based primarily on self-reported symptoms. This omission violates the Employee Retirement Income Security Act (“ERISA”). The Court emphasized that, “Unum proffers no reason, and none is apparent, for its highlighting the loss of benefits that results from the application of the mental illness and substance abuse limitations in three different places in the SPD while omitting the self-reported symptoms limitation, which is part of the same provision in the plan.” The self-reported symptoms limitation, the Court said, is not an “idiosyncratic contingency” concerning only a few people but rather a broad exception to the continuation of benefits that should reasonably be included in the SPD.
Because the SPD failed to “reasonably apprise” Sue of the self-reported symptoms limitation and this limitation is relevant to a wide spectrum of plan participants, the SPD does not satisfy ERISA. The 7th Circuit has ordered the district court to provide Sue with remedies which return her to the status quo, including benefits, interest and attorney’s fees.
Alan Olson writes this web-log to provide information regarding long-term disability cases. He practices long-term disability law throughout the United States from his offices in New Berlin, Wisconsin. Attorney Olson may be contacted at [email protected] with questions about the information posted here or for advice on specific disability benefit claims.
