Court Finds Louisiana Woman Suffering From Fibromyalgia Exhausted Her Appeals Before Filing A Lawsuit Against Unum
A court in Louisiana found a woman properly exhausted her appeals before filing a lawsuit against Unum. Thus, the court found that Unum could not use evidence gathered after Ms. Wittman filed the lawsuit.
ERISA and The Administrative Record
Like most claims for long-term disability benefits, Ms. Wittman’s claim was governed by the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA, claimants are required to appeal the denial of long-term disability benefits.
Once an appeal is denied, neither the claimant nor the insurance company is able to present new evidence. It does not matter how favorable this evidence may be. The file is effectively closed and then presented to a judge for a decision.
Ms. Wittman’s Long-Term Disability Claim
Before her disability, Ms. Wittman worked as an attorney. Her medical conditions, namely fibromyalgia, forced her to stop working in December of 2013. She then filed a claim for long-term disability benefits with Unum.
Ms. Wittman’s claim for long-term disability benefits was denied in October of 2014. She appealed Unum’s decision twice. Both appeals were denied.
Before filing a lawsuit, Ms. Wittman submitted to Unum notice that the Social Security Administration found she was disabled. In January of 2017, Unum granted Ms. Wittman mental health disability benefits for 24 months. In July of 2017, Unum asserted that no additional benefits were payable as Ms. Wittman was not physically disabled.
Ms. Wittman filed a lawsuit against Unum in September of 2017. In February of 2018, Ms. Wittman also appealed Unum’s most recent denial. Unum ultimately denied this appeal as well. To reach this conclusion, Unum hired a doctor to perform a “peer review” of the medical records. In February of 2018, Unum’s doctor found Ms. Wittman was not physically disabled.
Issues Before the Court
Ms. Wittman asked the court to strike all evidence created after she filed a lawsuit against Unum. In response, Unum argued that all post-lawsuit documentation should be a part of the evidence. Importantly, Unum wanted to include the peer review it had performed in February of 2018.
Unum also argued that the lawsuit should be dismissed because Ms. Wittman did not exhaust her appeals before filing a lawsuit. Its contention was that Unum’s denial of benefits in July 31, 2017 was an initial denial of benefits which required Ms. Wittman to appeal.
The Court’s Decision
This court focused its review on whether Ms. Wittman had exhausted her appeal before filing the lawsuit. The court notes that in Unum’s denial letter dated July 20, 2015, it advised Ms. Wittman that the review of her appeal was complete and no further review was available. The court was not persuaded by Unum’s argument that its July 31, 2017 decision was an initial denial of benefits requiring an appeal.
Thus, the court concluded that Ms. Wittman exhausted her appeals in July of 2015 and that all documents generated after the filing of the lawsuit were excluded from the record and would not be considered by the Court.
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