Court of Appeals, Seventh Circuit ruled Unum Life Insurance Company Of America is prevented from using Self-Reported Symptoms Limitation Clause to discontinue long term disability benefits payments for woman with fibromyalgia

In the case of Susie Weitzenkamp, Vs. Unum Life Insurance Company Of America, the Court of Appeals, Seventh Circuit recently ruled that the Unum Life Insurance Company Of America (UNUM) cannot rely on a Self-Reported Symptoms Limitation Clause to discontinue the plaintiff’s long term disability benefits as UNUM had failed to include the self-reported symptoms limitation in the Summary Plan Description (SPD).

The Facts of the UNUM Case – Discontinuation of Long Term disability Benefits Due to Self-Reported Symptoms Limitation

The plaintiff Susie Weitzenkamp worked at Time Warner Cable Inc. as a sales representative and participated in a plan, which is governed by the Employee Retirement Income Security Act (ERISA) and administered by UNUM. The plan gives Unum discretion to determine eligibility and to interpret the plan’s terms. The plaintiff was awarded long term disability benefits by UNUM after she was diagnosed with fibromyalgia, chronic pain, anxiety, and depression. However, after a little more than twenty four (24) months later, UNUM discontinued the plaintiff’s long term disability benefits on the ground that she had received all to which she was entitled under the plan’s self-reported symptoms limitation.

Under the self-reported limitation as defined in the Plan, benefits cease after twenty-four months for those with “[d]isabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness, alcoholism or drug abuse.

Self-reported symptoms were defined in the plan as “the manifestations of your condition which you tell your doctor that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine.” The plan also provided a non-exhaustive list of self-reported symptoms: “headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy.

The District Court for Eastern District of Wisconsin’s Ruling

After exhausting all her administrative remedies, the plaintiff and her disability attorney filed a lawsuit at the District Court for Eastern District of Wisconsin challenging UNUM’s application of the self-reported symptoms limitation to discontinue her long term disability benefits. Upon judicial review, the District Court ruled that Unum’s discontinuation of benefits based on a finding that the plaintiff was not disabled was an arbitrary and capricious decision. However, the district court upheld Unum’s application of the self-reported symptoms limitation.

Appeal to the Seventh Circuit Court of Appeal

On appeal to the Court of Appeal, the plaintiff challenged UNUM’s decision to discontinue the disability benefits on the ground that Unum’s failure to include the self-reported symptoms limitation in the SPD estops it from relying on the limitation as a basis for its decision.

The Court of Appeal’s Opinion

The Court of Appeals ruled that the failure to include the self-reported symptoms limitation in the SPD is a defense against its application and thus was properly raised in response to Unum’s cross-motion in the plaintiff’s combined response and reply brief.

The Court of Appeal opines that the SPD is intended to be a “capsule guide [to the plan] in simple language.” Although it need not “anticipate every possible idiosyncratic contingency that might affect a particular participant’s or beneficiary’s status,” it must “be sufficiently accurate and comprehensive to reasonably apprise such participants and beneficiaries of their rights and obligations under the plan.

The Court of Appeal further stated that in addition to providing identifying information about the administrator of the plan, an SPD must include “the plan’s requirements respecting eligibility for participation and benefits” and “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits.” Hence, if the SPD does not “… satisfy ERISA’s disclosure requirements, a court may estop a plan administrator from denying coverage for terms not included in the SPD but found in the underlying plan.

In the Plaintiff’s case, the SPD clearly sets out that long-term benefits will be discontinued after twenty-four months if a participant’s disability is due to mental illness or substance abuse. However, it does not mention that if a participant’s disability is based primarily on self-reported symptoms, long-term benefits will be discontinued after twenty-four months. The Court of Appeal ruled that this omission violates the provisions of ERISA and UNUM offered no reason why this limitation was omitted in the SPD while the application of the mental illness and substance abuse limitations in appeared three different places in the SPD. The Court of Appeal stated that because the self-reported symptoms limitation concerns a broad spectrum of plan participants, it should be reasonably included in the SPD.

The Court of Appeal’s Ruling

Hence, UNUM is therefore prevented from relying on the self-reported symptoms limitation in denying the plaintiff’s benefits. The Court of Appeal reversed the District Court’s judgment on this issue and remanded with instructions to order Unum to reinstate the plaintiff’s benefits retroactive to August 22, 2008.

Comments (2)

  • Karen,

    If your policy provides discretionary authority to Unum to interpret the terms and conditions of same, and your condition falls within the self-reported condition language in the policy, then Unum does have the right to apply the limitation to your claim for benefits. However, just because Unum is claiming that your condition is a “self-reported” one doesn’t necessarily make it so, or mean that your claim cannot be worked to get beyond the 24 month period. Please feel free to contact our office to discuss your claim to determine if there is a way to get around the imposed limitation.

    Stephen Jessup Jun 19, 2013  #2

  • I have just been approved for LTD under my employer’s policy and that was just a few days after I was terminated from my job. I was told by the UNUM agent that because my illness is considered a self-reported condition, I would only be eligible for 24 months of coverage rather than the 60 months for other conditions. I hope I won’t need it, but can they do this, can they cut off my benefits so arbitrarily?


    Karen Gardner Jun 18, 2013  #1

Leave a comment or ask us a question

Questions About Hiring Us

Do you help Unum claimants nationwide?

We represent Unum clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Unum disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Unum. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Unum.

How do you help Unum claimants?

Our lawyers help individuals that have either purchased a Unum long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Unum:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

William K.

At the start of this journey I was not feeling very positive. The letters from my insurance company and their phone calls gave me little hope. I met with Mr. Jessup and he reviewed my file with me carefully and he explained his feeling very carefully to me. He was positive and I felt a sense of honesty and concern. The process did take a few month and I was not very positive. This firm continued to ask me to hang in there and we will fight for what you deserve. Their honesty and positive communication was so helpful to me. Mr. Jessup and his support staff always returned my calls and gave me hope. My claim for long term disability benefits was approved.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us