Disability insurance cases usually have similar fact patterns, but it’s rare that you see a case that involves an attorney as a claimant, blackmail from a convicted claimant, and Unum attempting to recover over $1,000,000 in previously paid long term disability benefits. On March 31, 2014, The US Supreme Court denied a long term disability insurance claimant’s Counsel for Petitioner, Petition for a Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, relative to the case Truitt v. Unum Life Insurance Co., and presented the following questions:
1) Where an ERISA plan beneficiary brings suit to enforce the terms of a benefit plan, may the plan fiduciary then seek by counterclaim to have the beneficiary pay back benefits it already provided, a purely legal remedy unauthorized by ERISA, without undermining the will of Congress, the clear provisions of ERISA and this Court’s decisions interpreting its provisions?
2) Should Unum’s structural conflict of interest together with its history of biased claims administration act as a “tiebreaker” favoring allowance of petitioner’s disability claim where its decision-making process in denying petitioner benefits was procedurally unreasonable?
3) Were both federal courts below bound by Illinois law to employ a de novo standard of review in assessing respondent’s denial of petitioner’s disability benefits?
Facts relative to Question 1) Where an ERISA plan beneficiary brings suit to enforce the terms of a benefit plan, may the plan fiduciary then seek by counterclaim to have the beneficiary pay back benefits it already provided, a purely legal remedy unauthorized by ERISA, without undermining the will of Congress, the clear provisions of ERISA and this Court’s decisions interpreting its provisions?
Ms. Truitt was employed as a law firm partner and trial attorney/arbitration lawyer. She stopped working in 2002 due to persistent back pain despite surgery which was aggravated by the physical demands of her occupation which required frequent travel, frequent sitting and heavy lifting, among other duties.
Ms. Truitt was awarded benefits in 2003. Unum terminated Ms. Truitt’s benefits in 2006 due to purported findings in an FCE, an “independent” medical examination, and a file review, all conducted by physicians hired by Unum. Ms. Truitt appealed the denial and Unum reversed its decision in 2007 following a vocational file review conducted by Unum’s hired consultant which supported Ms. Truitt’s disability claim.
The Black Mail
A month after Ms. Truitt’s benefits were reinstated, Unum was contacted by one Andrew Thomas who, in exchange for money, offered to provide Unum with information that one of its insured was obtaining disability benefits under false pretenses. It is noted that Mr. Thomas is a career thief with multiple felony convictions and incarcerations who had pled guilty and been deported for physically assaulting Ms. Truitt while traveling with her and he had already tried to blackmail Ms. Truitt. Unum did not agree to pay Mr. Thomas but encouraged him to provide any information he possessed.
In late 2007, another of Unum’s hired physicians concluded that Ms. Truitt continued to be disabled and unable to work, and search of business records confirmed that Ms. Truitt had not been practicing law or claiming business income since she went out on disability.
Once Mr. Thomas was released from prison for the assault conviction in 2008, he again contacted Unum, claimed he had a personal relationship with Ms. Truitt and provided computer-generated emails during the time period of 2005-2007 which he claimed showed that Ms. Truitt had extensively traveled overseas and was performing legal work as an attorney. Without verifying the information provided by Mr. Thomas, in 2009, Unum suspended payment of disability benefits. In addition to the alleged email evidence, two of Unum’s hired physicians and Unum’s vocation consultant concluded that Ms. Truitt was no longer disabled and was able to perform the duties of her own occupation. Ms. Truitt’s benefits were terminated in October 2009.
Unum Seeks $1,018,098.36 In Overpaid Disability Benefits
Based on the alleged emails, Unum determined that Ms. Truitt had ceased being disabled as of March 2005, and because she wrongfully received benefits during that time period through August 2007, she owed Unum $1,018,098.36 in overpaid benefits.
Ms. Truitt filed an administrative ERISA appeal, but in 2010 Unum upheld the decision to terminate her benefits and sought payment from her in the amount of $1,018,098.36, which represented overpayments.
Ms. Truitt filed suit in the Western District of Texas, Austin Division under ERISA and Unum filed a counterclaim to recover the $1,018,098.36 it alleged Ms. Truitt had fraudulently obtained.
Claimant Wins at Texas District Court & Gets Reversed by 5th Cir. Ct. of Appeals
Unum moved for judgment on both Ms. Truitt’s complaint and on the counterclaim, which Ms. Truitt opposed. In his order dated 1/19/2012, District Judge J. Sparks denied both of Unum’s motions, declared Unum’s decision to terminate benefits arbitrary and capricious, ordered reinstatement of benefits from and after October 2009, and awarded Ms. Truitt reasonable attorney’s fees.
Unum appealed the District Judge’s ruling and in September 2013, the Fifth Circuit Court of Appeals unanimously reversed the district court’s ruling and entered a judgment in favor of Unum. The appellate court also vacated the ruling on Unum’s counterclaim and award of attorney’s fees to Ms. Truitt and remanded these matters to the district court for further proceedings. With regard to the counterclaim, the appellate court ruled that federal common law, not Texas law, applied as ERISA does not provide for how a plan administrator may recover benefits which it alleges were fraudulently obtained. Under federal common law, the court of appeals concluded that Ms. Thomas’ emails were sufficiently reliable to support a conclusion that Ms. Truitt was able to work in her occupation, and it vacated the district court’s finding that Ms. Truitt did not fraudulently obtain benefits and remanded this issue for further proceedings.
A petition for rehearing en banc was denied by the court of appeals.
In the Petition for a Writ of Certiorari, Ms. Truitt points out that District Judge Sparks ruled that Unum failed to present evidence on its counterclaim that Ms. Truitt made false representations regarding her disability or that it had relied upon false representations, which is required under Texas law, because Unum had conducted its own independent investigation of Ms. Truitt’s disability claim. On this basis, Judge Sparks denied the motion for judgment on Unum’s counterclaim.
In replacing Texas law with federal common law, the court of appeals determined that Unum could still pursue the counterclaim for money damages based on alleged fraud and, by remanding the issue, the court of appeals resurrected the counterclaim seeking damages on the basis that Ms. Truitt had not been entitled to said benefits as of March 2005 and that she obtained the benefits through an act of fraud.
In the Petition, counsel for Ms. Truitt sets out that 29 U.S.C. §§ 1109(a) and 1132 (a)(1)-(5), provides plan beneficiaries and plan trustees with a number of equitable remedies when either one fails to comply with their duties under ERISA. However, ERISA does not provide plan fiduciaries the right to seek compensatory money damages from a plan beneficiary for benefits already paid. ERISA allows for awards which are equitable in nature, not legal, when there is an identifiable fund or separate property on which a levy or equitable lien may be imposed. A remedy for restitution in the form of money damages is legal, not equitable in nature because it seeks to impose a personal liability upon [Ms. Truitt in the instant case] to pay a sum of money. Additionally, even if it can be concluded that the money is property which belongs to Unum, it is no longer in the hands of Ms. Truitt and Unum, therefore, Unum assumes the role of a general creditor seeking to impose personal liability on Ms. Truitt, which is a purely legal action unauthorized under ERISA.
Counsel for Ms. Truitt unsuccessfully argued that, by allowing the counterclaim for monetary damages, the court of appeals contravenes the precedent set forth by Great West and Mertens, and undermines the intent of Congress, reinforced by Great West, that fiduciaries like Unum are not authorized by ERISA to seek this form of legal relief against a plan beneficiary. Further, the district court, to whom the court of appeals remanded this issue, lacks the jurisdiction to conduct further proceedings with regard to the counterclaim and said counterclaim should be dismissed.
Facts relative to Question 2) Should Unum’s structural conflict of interest together with its history of biased claims administration act as a “tiebreaker” favoring allowance of petitioner’s disability claim where its decision-making process in denying petitioner benefits was procedurally unreasonable?
District Judge Sparks determined that his deferential review of Unum’s denial of benefits must account for the inherent conflict of interest, as Unum both determined Ms. Truitt’s eligibility for benefits and then paid those benefits out of its own pocket. Judge Sparks noted that this factor was of “perhaps great importance” which can act as a tiebreaker in Ms. Truitt’s favor in this matter because Unum also had a well-known history of biased claims administration, as observed by the Glenn court.
Because Unum relied so heavily and put such great weight on the emails produced by Mr. Thomas, despite the fact that Ms. Truitt disputed the emails and that Mr. Thomas was a career criminal who previously tried to extort Ms. Truitt, Judge Sparks concluded Unum’s decision was arbitrary and capricious. Judge Sparks did note that, though substantial evidence supported Unum’s decision, the method by which Unum reached the decision was unreasonable. The structural conflict of interest became more important under the circumstances and became a “tiebreaker” for Judge Sparks to determine that Unum abused its discretion.
The court of appeals agreed that a structural conflict of interest existed for Unum. However, it ruled that Judge Sparks gave improper weight to the conflict when Unum had carefully considered Ms. Truitt’s claim and had publicly adopted new claims-handling practices that supposedly eliminated any biased claims administration. Moreover, even if the conflict of interest were of “great importance”, the record contained substantial evidence supporting Unum’s decision, indicating no abuse of discretion.
In the Petition, counsel for Ms. Truitt argued that, under Firestone and Glenn, federal courts reviewing a denial of benefits under the discretionary standard of review, when the fiduciary was operating under a conflict of interest, must employ a “combination-of-factors” method of review which takes into account the conflict itself, as well as any other factors which suggest the denial decision was unreasonable. The Glenn court ruled that a plan administrator’s conflict could be of “great importance” and become a “tiebreaking” factor favoring the petitioner when circumstances suggest the conflict affected the benefits decision.
Counsel for Ms. Truitt argued that the court of appeals “unwound” Glenn’s analysis by basically dismissing Unum’s tainted history and then by removing any duty Unum had to verify the authenticity of Ms. Thomas’ emails. The court of appeals cited to 3 prior decisions which noted Unum’s new claims handling practices and that those particular cases “diluted” this factor in deciding whether Unum abused its discretion. Counsel argued that reference to those 3 cases demonstrate that Unum’s conflict of interest and history of biased claims administration “is always the backdrop when a district court evaluates Unum’s denial of benefits for abuse of discretion; and the degree to which its past abusive practices enter into the calculus is not its unsubstantiated assertion that it has adopted new claims handling practices but whether it has employed those new practices in that particular case.”
Facts relevant to Question 3) Were both federal courts below bound by Illinois law to employ a de novo standard of review in assessing respondent’s denial of petitioner’s disability benefits?
Both parties agreed that Illinois law, to the degree not preempted by ERISA, was the governing law under the subject insurance contract. In 2005, Illinois initiated a regulation (50 Ill. Admin. Code § 2001.3) which prohibited the use of discretionary clauses in disability policies and required all courts to apply a de novo standard of review in ERISA cases which challenge a denial of benefits. Initially this regulation applied only to policies that were issued after 7/1/2005. However, in 2008, the Illinois Director of Insurance issued a bulletin instructing that this regulation will apply to all disability policies that were “issued or renewed” since 7/1/2005.
In the Petition, counsel for Ms. Truitt states that Ms. Truitt’s disability plan existed prior to 2005 and gave Unum discretionary authority. However, the policy was renewed on December 1st of every year. Additionally, on 11/1/2005, the policy was amended to make a material change in one of the provisions and therefore was issued anew. Based on these facts, Ms. Truitt was entitled to a de novo review. Counsel for Ms. Truitt also noted that the court of appeals in this matter (the Fifth Circuit), was in direct conflict with courts of appeals in the Sixth and Ninth Circuits, who both upheld state laws barring discretionary clauses in disability plans and mandating de novo review of denial of ERISA plan benefits.
The Supreme Court of the United States denied Ms. Truitt’s Petition for Writ of Certiorari without further explanation or discussion.
Read more about Unum disability claims.