A former teacher from Texas is bringing an Unum lawsuit to seek reversal of a disability claim denial.

Plaintiff Kimberly H. says that as a former employee of Child Inc., working as a Head Start Teacher, she was a participant in a long term disability insurance plan administered by Unum Life Insurance Company of America.

Kimberly alleges she became disabled in June 2013. The Social Security Administration found her to be totally disabled under its own standards, she says.

She also says she made a timely claim for disability benefits from Unum. Unum at first granted Kimberly’s claim, but then denied it, she says. She claims her appeal to Unum was also denied in March 2014.

Having exhausted all her administrative remedies, Kimberly is now bringing this Unum lawsuit. She seeks recovery of the benefits she says she has been denied and clarification of her rights to continue receiving benefits in the future.

Bringing an Unum Lawsuit Under ERISA

Kimberly’s claim in this Unum lawsuit is governed by the Employee Retirement Income Security Act, a federal law enacted in 1974 to protect employees’ benefits.

Though initially enacted to protect claimants, some experts are now of the opinion that subsequent amendments and court decisions have made ERISA more favorable to the insurance company.

While there are analogous state laws that often provide more claimant-friendly protections, these typically to privately purchases insurance plans. Most employer-sponsored disability benefits are governed by ERISA, which pre-empts state laws that would conflict with it.

In an ERISA appeal, a claimant may be able to recover benefits, but not much else. Some state laws allow for recover of damages that could compensate for some of the harm caused by the denial of benefits, and sometimes they may provide for punitive damages to punish companies that make wrongful denial.

Claimants who succeed in their appeals may also be entitled to recover attorneys’ fees and court costs. These benefits are rarely available in an ERISA appeal, if ever.

An ERISA appeal in federal court doesn’t involve a “trial” in the traditional sense. Typically, the judge – not a jury – will review the same evidence that was before the insurance company when it made its disability claim denial.

For that reason, attorneys often recommend that claimants make sure to present all supportive evidence to the insurance company before it makes its final denial, since there won’t likely be a chance to present more evidence to the court.

Generally, insurers of an ERISA-governed policy are allowed broad discretion to decide who is or is not entitled to benefits. That discretion means that a judge is less likely to second-guess the insurance company’s denial when the claimant appeals. It’s possible to prove that an insurer abused its discretion, but making that argument is very difficult and not often successful.

There are many other technical ins and outs associated with appealing a disability claim denial under ERISA. An experienced attorney can help claimants navigate the process and get all the benefits they are rightly entitled to.

The Unum Lawsuit is Case No. 1:16-cv-00646, in the U.S. District Court for the Western District of Texas.