Legal Summary: Willard v. Unum Life Insurance Company of America
Willard v. Unum Life Insurance Company of America
1:20-cv-125, (6th Cir. 2022)
We filed suit against Unum Life Insurance Company of America on behalf of our client, whose benefits were wrongly terminated.
Our client filed for short-term disability benefits due to his condition. Unum approved these benefits, paying for the maximum term of twenty-six weeks. Unum told our client that his claim would transfer from short-term disability into a long-term disability claim, but that he would not necessarily be approved for long-term disability benefits. Unum then began to review his claim.
Unum decided our client was not disabled under its plan. We then filed a timely claim that Unum failed to provide his disability benefits in violation of the Employee Retirement Income Security Act of 1974.” (“ERISA”), 29 U.S.C. § 1001, et seq.
We argued that Unum’s decision to deny our client’s benefits was arbitrary and capricious.
Under ERISA, when a policy contains a “clear and express grant of discretion” to the administrator, the court will not overturn the administrator’s decision unless that decision is arbitrary and capricious. Unum agreed to have the case tried under this standard of review.
In order to prove that a decision was not arbitrary and capricious, per Shaw v. AT&T Ben. Umbrella Plan No. 1, 795 F.3d 538, 547 (6th Cir. 2015), the plan administrator must offer a reasonable explanation. When evaluating a decision as arbitrary and capricious, the courts must consider whether a physical exam was performed.
We argued that Unum’s denial was arbitrary and capricious as its file reviewers refused to physically examine our client, relied on its in-house file reviewers’ credibility determinations, relied exclusively on Unum’s own doctors to deny our client’s claim, and failed to meaningfully evaluate the medical evidence he presented.
Unum argued that its failure to examine our client was not arbitrary and capricious, but our client’s physicians had recommended a physical examination and functional disability assessment. Unum arbitrarily denied performing an examination, avoiding additional evidence that had a reasonable likelihood of confirming our client’s disability.
The court found numerous instances of the file-reviewing doctors discrediting our client’s subjective complaints and failing to rebut evidence of his disability. Unum’s file review was “clearly inadequate” as it was not based on a “reasoned or rational reading” of the evidence provided. The court also found “substantial” objective medical evidence in our evidence that supported our client’s disability status. Per Gilrane v. Unum Life Ins. Co. of Am., No. 1:16-CV-403, (6th Cir. 2017), the Sixth Circuit determined that a file-only review is arbitrary and capricious if it did not adequately consider the record or if the insured provided significant objective medical data to support their disability claim.
The court ultimately ruled in our favor, remanding the case to Unum for a “properly considered and explained determination” of our client’s benefit eligibility.
