naremove: This example highlights the importance of ensuring that disability benefit decisions are based on reading and applying management plan documents and claims procedures. Here, the court’s decision was largely based on his Unum’s failure to focus on the symptoms of disability actually experienced by the plaintiff, contrary to the “plain language” of the policy. Instead, Unum concluded that the plaintiff’s symptoms were atypical and therefore unreal. In doing so, the court concluded that Unum had inappropriately deviated from its policy.
The decision also cautions plan managers to take a holistic, rather than academic, view of disability claims. The court upheld the conclusions drawn from the face-to-face research over those drawn from the paper-only review because the plaintiff’s actual provider was “in a better position.”[ed] The irrefutable evidence shows that plaintiffs have trouble with written and oral communication and with the use of computer screens, so the court finds plaintiffs unable to perform the work that requires them. It was judged.
A Minnesota federal district court ordered administrators of long-term disability (LTD) benefits policies to retroactively reinstate former employee benefits and pay attorneys’ fees, overruling a decision to terminate benefits three years ago. .
Courts have held that if the policy requires assessing the existence of “disability” “by focusing entirely on claimant limitations,” administrators should “not allow ordinary people with similar illnesses or injuries to or how the typical person progresses after an event that causes an illness or injury. She rejected her symptoms and failure to properly trust the assessment of the health care provider who personally examined her.
The plaintiff worked as a call center supervisor and was a heavy computer user who needed to read, write and type. After suffering a concussion in a car accident in February 2018, she developed headaches, sore eyes, visual disturbances, dizziness, fatigue and impaired short-term memory, concentration, communication and other cognitive functions. Reported. Her health care provider verified these reported symptoms and diagnosed her with various visual and cognitive impairments. I did not allow her to work until she was released to work three non-consecutive days a week.
In March 2018, plaintiff applied for LTD benefits to Unum Life Insurance Co. of America, the administrator of the employer’s LTD policy. After gathering information about her condition and conducting its own due diligence, the Unum approved her claim in November 2018.
Unum terminated the plaintiff’s benefits in January 2020, concluding that her medical records “did not support her opinion.” [her] Specifically, Unum concluded that her injuries were not consistent with long-term functional impairment that was otherwise not substantiated by physical findings. Similarly, Unum rejected and explained the plaintiff’s subsequent appeal on similar grounds. Most recovered from similar injuries within three months, but her symptoms “worsened over time” and “did not match the usual trajectory”, again “self-reported” and corroborated There was no
Plaintiffs have filed prompt claims under the Employee Retirement Income Security Act (ERISA). Both parties filed cross-movements for judgment of the administrative record providing for de novo review.
Deciding in favor of the plaintiff, the court rejected Unum’s rationale that she “has not improved as expected and is no longer disabled.” The court explained that the policy’s plain language “makes it clear that disability is assessed only by the claimant’s limitations, rather than by the typical or usual trajectory,” and that “most people will not seek improvement.” regardless of whether or not
The court also dismissed Unum’s disregard for plaintiff’s self-reported symptoms. Because the policy “specifically recognizes self-reported symptoms” as the “primary basis” for disability determinations, Unim initially relied on the same evidence when granting benefits. The court emphasized that no one who personally examined the plaintiff questioned her credibility, but instead argued that she remained largely unable to work. Unum’s own claims manual, which has not investigated plaintiffs, states that arguments based on first-hand investigation should only be dismissed if specific explanations are provided. The reviewer neglected this.
Finally, the court found that if plaintiff’s work required constant use of a keyboard, sight and depth perception, the evidence showed that she had difficulty communicating, typing e-mail, and working with a computer screen. , determined that she was no longer able to perform her duties. her cognitive impairment and headaches; The court therefore concludes that the plaintiff was disabled when Unum terminated his benefits and instructed Unum to continue to receive benefits until he was disabled or unless he provided the required evidence showing that his disability continued. ordered to be restored retroactively. The court also ordered her to pay Unum reasonable attorneys’ fees in light of the nature and purpose of ERISA’s relief.
Proctor v. Unum Life Insurance Co. of AmericaD. Minn., No. 20-2472 (29 September 2022).
Brian W. Sullivan is an attorney in the Philadelphia office of Duane Morris LLP.