District Court Finds Review of Disability Claim and Appeal Not Compliant with ERISA

On February 29, 2024, in Black v. Unum Life Insurance Company of America, the Federal District Court for the Northern District of Texas granted in part the motion for summary judgment by Black (the plaintiff), determining that Unum (the defendant) failed to provide a full and fair review of plaintiff’s long-term disability claim. The court remanded the matter back to the defendant to review the claim in line with ERISA requirements.

The plaintiff received long-term disability claims through her employer under a plan administered by the defendant. In September 2021, the defendant denied a claim submitted by the plaintiff, asserting that the plaintiff was no longer disabled. The defendant stated that it reviewed the medical records and talked with the treating medical providers as part of its review. The plaintiff appealed the denial. The defendant’s employee, a nurse, determined that there was no medical disagreement among the plaintiff’s physicians regarding her functionality and denied the claim on appeal. The defendant declined to review the claim denial again, so the plaintiff filed the lawsuit, alleging that the defendant failed to provide a full and fair review of her claim as ERISA requires.

The court applied a substantial compliance standard when evaluating the defendant’s review. Under ERISA, an appeal of an adverse determination of a claim based upon medical judgment must include consultation with a medical professional with training and experience in the field of medicine involved in the medical judgment. The medical professional cannot be the same person who was consulted for the original determination. Since the initial denial was based on a review of medical records and consultations with the plaintiff’s doctors, the court concluded that the initial denial was based on medical judgment. However, the court determined that the nurse who conducted the appeal review deferred to the opinions of the doctors in the original review. In addition, the nurse was not qualified to conduct the appeal review because she did not have the appropriate experience and training. Accordingly, the court determined that the defendant failed to substantially comply with ERISA requirements.

Employers that offer long-term disability benefits to their employees should be aware of ERISA claim review and appeal requirements and take steps to ensure that the applicable procedures for their long-term disability plans comply with ERISA’s requirements, including conferring with their disability carriers on the subject, where applicable.

Black v. Unum Life Insurance Company of America »