A Georgia disability attorney recently filed a federal ERISA disability lawsuit against Boston Mutual Insurance Company of America and Disability Reinsurance Management Services (DRMS) to recover long-term disability benefits that were wrongfully withheld.
The plaintiff was employed by Green Island Country Club who contracted with Boston Mutual Insurance Company to provide disability benefits to its employees. By virtue of his employment, the plaintiff was covered by Green Island Country Club’s Overall Welfare Benefit Plan.
The Facts of the Case Against Boston Mutual Insurance Company
The disability policy terms issued by Boston Mutual to Plaintiff defines “disability” and Boston Mutual’s financial responsibilities to disabled Participants as follows:
- Participant is not able to perform some or all of the material and substantial duties of his/her regular occupation and have at least a 20% loss in pre-disability earnings OR
- Participant is not able to perform some or all of the material and substantial duties of his/her regular occupation, is working in any occupation, and have had at least a 20% loss in his/her pre-disability earnings.
- Boston Mutual will provide payment beyond 24 months if Participant is disabled as defined above AND
- Participant is not able to continue performing one or more activities of daily living (ADL) without stand-by help OR
- Participant has a terminal illness
Plaintiff went on disability October 4, 2007, was found to be disabled, and was paid up until January 2, 2010.
Denial of Boston Mutual Benefits Claim
By letter dated May 14, 2009, Boston Mutual terminated Plaintiff’s benefits due to not enough medical evidence supporting disability claim.
On July 19, 2010, Plaintiff hired services of a disability lawyer who ordered the claims file.
The attorney discovered on or about August 24, 2010 via the claims file that a denial letter was dated December 23, 2009. Plaintiff did not appeal this denial within the 180-day period.
Plaintiff, through the attorney, requested DRMS via certified letter on August 24, 2010 to reopen the file, as it appeared that the Plaintiff was very mentally slow. Plaintiff added updated medical records to the file.
On September 7, 2010, Plaintiff received letter from DRMS that returned all of Plaintiff’s information and that stated that since the Plaintiff missed the 180-day period to appeal by 2 months, DRMS would not reopen Plaintiff’s claim.
On September 13, 2010, Plaintiff, via letter through the attorney, informed DRMS that he was uncertain whether he even received the denial letter from December 23, 2009. Since DRMS did not send the letter by certified mail or via any other traceable method, DRMS could not prove that it was sent, so Plaintiff asks again for DRMS to reopen the file, reiterating again that Plaintiff is very mentally slow.
On September 15, 2010, Plaintiff sends additional information and asks DRMS to reopen the file.
Two more attempts to reopen the file were denied by DRMS, even with an inclusion of a Neuropsychological Evaluation that showed that the Plaintiff had a cognitive disorder that caused severe deficits in his attention, concentration, visual memory, and processing speed.
Disability Lawyer Files Lawsuit Against Boston Mutual And DRMS
According to the lawsuit, Plaintiff alleged that Boston Mutual and DRMS have failed to:
- Provide their fiduciary duties to Plaintiff under ERISA
- Provide benefits stated in the policy
Relief Sought By The Plaintiff In The Boston Mutual And DRMS Lawsuit
As a result of Boston Mutual and DRMS’ actions, the Plaintiff seeks the following relief from the Court:
- Place judgment against Boston Mutual and DRMS for all disability benefits from January 2, 2010 and beyond, as well as interest on all back benefits OR
- Grant a remand to the administrative level and order the Defendants to consider additional medical evidence that allows the Plaintiff access to a full and fair review
- Place judgment that Defendants violated their fiduciary duty to Plaintiff and order the denial of benefits to claim to be reviewed under the de novo standard of review OR/AND place judgment that Defendants may not reduce amount of benefits from past benefits due or from future benefits to be received
- Award attorney’s fees, litigation expenses, and court costs
- Grant all other just and proper relief as Court deems appropriate