Case Conclusion Date: 07.11.2011
Practice Area: Employee Benefits
Outcome: Win for disabled client
Description: Unum Life Insurance Co. of America cannot rely on a disability benefit planâ€™s limitation on self-reported symptoms to terminate a plan participantâ€™s long-term disability benefits, the U.S. Court of Appeals for the Seventh Circuit ruled July 11 (Weitzenkamp v. Unum Life Insurance Co. of America, 7th Cir., No. 10-3898, 7/11/11). The three-judge appellate panel found that because the summary plan description did not include the limitation on self-reported symptoms, the SPD did not meet the Employee Retirement Income Security Actâ€™s disclosure requirements and thus Unum was estopped from relying on the plan limitation as a basis for discontinuing Susie Weitzenkampâ€™s benefits. SPD Omits Self-Reported Symptoms Limitation. Through an employer-sponsored plan administered by Unum, Weitzenkamp received long-term disability benefits for fibromyalgia, chronic pain, anxiety, and depression. Unum terminated Weitzenkampâ€™s benefits after 24 months under a plan provision that limited benefits to 24 months for disabilities due to sickness or injury that were primarily based on self-reported symptoms, and disabilities due to mental illness, alcoholism, or drug abuse. While the plan included these limitations, the SPD did not include the limitation on self-reported symptoms but did include the mental illness and substance abuse limitations in three different places. After unsuccessfully challenging her benefit termination with Unum, Weitzenkamp filed a lawsuit challenging the application of the self-reported symptoms limitation. SPD Violates ERISA. The Seventh Circuit found that Unum could not rely on the self-reported symptoms limitation, reasoning that, because the SPD did not include that limitation, it failed to reasonably apprise Weitzenkamp of her rights under the plan and therefore did not meet ERISA Section 102(b)â€™s requirements. Under Section 102(b), an SPD must include a planâ€™s requirements on eligibility for participation and benefits, and circumstances that may result in disqualification, ineligibility, denial, or loss of benefits. If an SPD does not satisfy these standards, a court may estop a plan administrator from denying coverage for terms not included in the SPD but found in the underlying plan, the appeals court said. The court said that while the self-reported symptoms clause had been omitted from the SPD, the same was not true for the mental illness and substance abuse limitations. Furthermore, the self-reported symptoms limitation was not an â€œidiosyncratic contingencyâ€ that only concerned a few people, but was a broad exception that should have been included in the SPD, the court said. As a remedy, the court ordered the reinstatement of benefits and payment of all back benefits, plus interest and attorney's fees.