A former radiology technician whose claim for long-term disability benefits was denied is now seeking reversal of that denial in court.

Plaintiff Barbara B. says in her Unum lawsuit she began working for Indiana University Health as a radiology technician in May 1996.

By May 2014, she says, she had become unable to work at any job due to arthritis in both knees, problems in her lumbar and cervical spine, and nerve damage in her feet.

Barbara applied for long-term disability benefits under the Unum Life Insurance Company of America benefit plan administered by Indiana University Health. Unum denied her claim in March 2015, then denied her subsequent appeal in July 2015.

Barbara now argues Unum’s denial was made in bad faith. Her Unum lawsuit alleges that she provided ample medical evidence showing she is disabled according to the terms of the employee benefits plan. She says she also provided opinions from her treating physicians saying she is “totally disabled from performing any occupation.”

Barbara argues that Unum’s denial of her claim violates the terms of the plan itself and of the federal Employee Retirement Income Security Act (ERISA). She is asking the court to order the defendants to pay benefits already withheld, with interest, and to continue paying future benefits as they come due. She also seeks an award of attorneys’ fees and litigation costs.

Barbara’s Unum lawsuit is pending in the U.S. District Court for the Northern District of Indiana under case no. 3:15-CV-386.

The Employee Retirement Income Security Act (ERISA)

ERISA is a federal law that, among other provisions, sets certain standards for the administration of long-term disability benefits provided as part of an employee benefit plan.

While ERISA nominally provides protections for the claimant, it also imposes several strict procedural requirements for any claimant who wants to appeal a denial. Claimants who want to preserve the option of bringing an ERISA lawsuit must follow these detailed requirements to the letter or risk having their ERISA lawsuit barred.

ERISA also provides for an internal appeal process to be conducted by the plan administrator. However, that appeal process is mandatory – a claimant wanting to appeal a denial must first appeal to the plan administrator before they can bring an ERISA lawsuit.

For claimants who want to appeal their denial before a court, ERISA imposes a standard of review that some say is in the insurance company’s favor.

Courts reviewing a denial of benefits under ERISA are concerned only with whether the insurance company abused its discretion or acted arbitrarily in its denial.

As a result, if the court finds any rational basis for denying the benefits, even if there is also some evidence the person is actually disabled, the court can affirm the denial.

That abuse-of-discretion standard contrasts with the “de novo” review that state laws generally applied prior to ERISA. Under de novo review, the court would make its own decision on the available evidence, with no deference to the insurance company’s denial.

Review by a court is also typically limited to the content of the file that the insurance company maintains for that particular claimant. For that reason, it is important for claimants to provide all their supportive evidence during the administrative appeal process.