Case Story: Our Client v. Provident Life and Accident Insurance Company

The plaintiff, in this case, our client, stopped working as a production assistant for Nissan due to lower back pain and took disability leave on December 15, 1999.  On June 16, 2000, our client submitted a claim for long term disability benefits under a group policy administered by Unum.  Id. at *1.  On July 23, 2000, Unum approved our client’s claim and paid them long term disability benefits until 2012.  Id. at *1.  In an April 11, 2012 letter, Unum notified our client that it was terminating their long term disability benefits and gave them 90 days to appeal the denial of benefits.

As explained in the summary of this case, Unum denied our client’s claim, because they said it was late when not appealed within the 90 days they gave them to appeal in their denial letter.  Unum’s position was that our client’s original policy allowed them only 90 days to appeal, and back when they first applied, the ERISA regulations at 29 C.F.R. § 2560.503-1 allowed an appeal deadline as short as only 60 days.  The ERISA regulations were revised January 1, 2002, to include a 180-day deadline to appeal the denial of disability benefits, but that only applied to new claims filed after January 1, 2002.  Id. at *3.  Unum claimed they could require our client to appeal under a short deadline because their claim was controlled by an old version of their policy and older pre-2002 ERISA regulations.  Id. at *2-*3.

Because our client’s policy and plan had been changed while they were getting paid benefits, to allow up to 180 days to appeal, we argued that 180 days applied to this appeal.  We agreed that Unum was technically correct that the older version of the ERISA regulations applied, and they could have required a deadline as short as 60 days.  But, when they amended the plan, the rule is that the deadline cannot be shorter than whatever is in the plan, even if the older regulations allowed a shorter deadline.  Thus, by amending the plan while our client was being paid, the new 180-day deadline applied to him.

Unum refused to consider our appeal, and we were forced to sue Unum in court on behalf of our client.   We sued under ERISA, contending that our client’s administrative appeal was timely and that they were entitled to their long term disability benefits under 29 U.S.C. §§ 1132(a)(1)(B).  Id. at *1.

The court ultimately agreed with us that Unum could not use the shorter deadline because the policy under which our client was covered had been amended while they were being paid benefits.  Id. at *3-*4.  The new version of the plan allowed for a full 180 days to appeal, as was required by the more recent ERISA regulations.  Id. at *3-*4.  The court ruled in our client’s favor that their appeal was filed on time and that Unum was arbitrary and capricious to require them to appeal in the shorter time.  Id. at *8-*9.

Rather than addressing whether our client was disabled or not, the court remanded the case back to Unum to require them to finish their decision-making process.  Id. at *9 (citing Shelby Cnty. they alth Care Corp. v. The Majestic Star Casino, LLC, 581 F.3d 355, 373-74 (6th Cir. 2009)(“[Where the plan administrator fails to comply with ERISA appeal-notice requirements in adjudicating a participant’s claim, the proper remedy is to remand the case to the plan administrator so that a full and fair review can be accomplished”); Elliott v. Metro. Life Ins. Co., 473 F. 3d 613, 621-622(6th Cir. 2006); Walsh v. Metro. Ins. Co., 2009 WL 603003 at *6-*7 (M.D. Tenn. Mar. 9, 2009)).

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