A Maryland woman is appealing the denial of her Unum disability benefits in federal court.

Plaintiff Asha G. used to work for Baja Fresh in Maryland as an operations manager, and as such was a beneficiary of a disability insurance policy provided to Baja Fresh employees through Unum Life Insurance Company of America.

Asha says she suffers from several different medical problems including lumbago, left shoulder impingement, and arthritis in both knees requiring knee replacement surgery.

In May 2013, Asha stopped working at Baja Fresh and began collecting short-term disability benefits while her application for long-term disability benefits was pending with Unum. Unum denied her claim for long-term benefits in December 2013, then upheld that denial on appeal in May 2014.

Asha then filed this disability insurance lawsuit against Unum. She argues that Unum failed to give her a full and fair review and that the denial was not supported by substantial evidence. She says the available medical documentation consistently shows that she is physically unable to perform even light-duty managerial work.

Asha is asking the court to order Unum to pay her the benefits she believes she is owed, including an award of retroactive disability payments amounting to over $100,000. She is also asking for an award of attorneys’ fees, as provided by federal statute.

Her disability insurance lawsuit is Case No. 1:15-CV-03449, filed in the U.S. District Court for the District of Maryland.

Unum Disability Benefits under ERISA

The disability insurance policy that Asha is suing for falls under control of a federal law called the Employee Retirement Income Security Act, or ERISA. ERISA governs the administration of many types of employee benefits – most notably retirement benefits, but also disability insurance.

After years of legal developments, some say ERISA now does more to protect insurers than claimants. One way they say it does so is by setting up a complicated and deadline-sensitive procedure for claiming disability benefits and appealing denials.

If the claimant wants to appeal a denied disability claim, the insurer gets a chance to review the denial before the claimant can file a disability insurance lawsuit – a concept known as exhaustion of administrative remedies. Claimants have up to 180 days to request that review, and insurers then have up to 90 days to consider it. For the insured, this means potentially 270 days without benefit payments before they can even get into court.

In court, the evidence is generally limited to whatever evidence was available to the insurer at the time of the denial. Because the claimant won’t get a chance to submit new evidence to the court, it’s crucial to ensure all supporting evidence is in the insurer’s file during the administrative process.

In court, that evidence will also be reviewed by a judge, not a jury. And as a matter of law, the judge has to give the insurer discretion in the way it decides claims on its own disability insurance policy.

Some other types of disability insurance policies fall under state laws that are more claimant-friendly than ERISA in many ways. These state laws may, for example, allow for submission of additional evidence that the insurer had not seen when it made the denial. There may also be more types of damage awards available under state law, including punitive damages in some cases. A successful plaintiff may also have better odds of recovering attorneys’ fees under state law than under ERISA.

Generally, whether state law or ERISA applies to a given disability insurance policy is determined by whether the policy was provided by an employer or whether it was purchased individually.