Susie Weitzenkamp was receiving long-term disability benefits because she was suffering from fibromyalgia, chronic pain, anxiety and depression.
The woman’s summary plan description (SPD) included a limitation in it that stated that benefits would stop after 24 months for people who had “disabilities, due to sickness or injury, which are primarily based on self-reported symptoms (symptoms where doctors have to rely more on patients describing their symptoms to reach a diagnosis).” Susie was approved for benefits and received them for 24 months when the company chose to terminate her disability insurance benefits because they figured that Susie had received everything she was entitled to under her plan’s self-reported symptoms limitations. Susie appealed that decision, but Unum stuck by its ruling.
After Susie filed a lawsuit in district court to have her disability insurance benefits reinstated, Unum decided to countersue her for overpayments that they said began when she started receiving social security benefits (which Unum’s policies force her to apply for). The district court decided that the extent of Unum’s cancelling of the woman’s benefits was based on them determining that she wasn’t disabled. The court also said that Unum’s decision was “capricious and arbitrary.” Yet it still decided to uphold the insurance company’s decision because of the company’s “self-reported symptoms limitation, in the SPD.” Worse still, the district court also ruled that Susie should pay the insurers $9,089 for benefits overpayment.
Things seemed bleak for Susie, but the appeals court disagreed with the first ruling and overruled it because “the plan’s self-reported symptoms limitation wasn’t in Unum’s Summary Plan Description,” and that the SPD was actually in violation of ERISA disclosure requirements. Because of that, the appeals court decided that it couldn’t be used as an excuse for the insurance company to claim overpayments.
In the end, the appeals court ruled that Unum has to reinstate Susie’s benefits and give her retroactive pay dating all the way back to the date that her payments stopped.
If your disability insurance benefits have been stopped by Unum; contact disability insurance attorney Greg Jones today for a free consultation. I am experienced at fighting insurance companies and helping my clients get the money that they may be entitled to.