A federal court has ruled against an insurance company and in favor of a disability claimant in a case involving interpretation of a summary plan description.
A 3-member panel at the 7th U.S. Circuit Court of Appeals agreed 3-0 to reverse a lower court ruling that favored Unum Life Insurance Company of America, a unit of Unum Group Corp., Chattanooga, Tenn. (NYSE: UNM).
The lower court ruling awarded summary judgment in favor of Unum and against Susie Weitzenkamp, a former sales representative for Time Warner Cable Inc., New York, who filed a claim for long-term disability (LTD) insurance benefits.
In 2006, Weitzenkamp started receiving LTD benefits after she was diagnosed with fibromyalgia, chronic pain, anxiety and depression.
Unum stopped paying benefits 24 months later citing a policy provision limiting payments to individuals whose injuries were based on self-reported symptoms.
A district court denied Weitzenkamp’s argument that her plan’s SPD referred only to a limitation on payments for either mental illness or substance abuse and contained no mention of the self-reported symptoms limitation.
The appeals court reversed the district court decision, noting that Weitzenkamp’s SPD referred to mental illness and substance abuse in three sections but contained no mention of the self-reported symptoms limitation.
“Unum’s failure to include the self-reported symptoms limitation in the SPD stops it from relying on the limitation as a basis for its decision,” District Judge Joan Lefkow writes in an opinion for the 7th Circuit panel.
The appeals court upheld Unum’s counter suit to recover $9,089 in overpaid benefits from Weitzenkamp, who received additional Social Security benefits in connection with her health problems.
Unum representatives declined to comment on the ruling.