Another lawsuit has been filed recently against the nation’s largest provider of disability insurance, the UNUM Life Insurance Company (UNUM) by disabled claimant of disability benefits under the Employee Retirement Income Security Act of 1974 (ERISA). In the case of Gwendolyn Soter v Reed Elsevier, Inc. Plan and UNUM life Insurance Company of America, the plaintiff Gwendolyn Soter through her Ohio disability attorney filed a lawsuit against the above mentioned parties at the District Court for the Southern District of Ohio alleging that UNUM had failed in its fiduciary duty by not discharging its administrative duties with respect to an employee welfare benefit plan solely in the interest of the plan’s participants.
The Nature of the Complaint
The plaintiff Gwendolyn Soter was working as a customer service representative at Lexis Nexis. While an employee at Lexis Nexis, she participated in an employee welfare benefit plan known as the “Reed Elsevier, Inc. Plan”. This plan was insured and administered by UNUM. In June 15th 2007, suffering from severe abdominal pain, chronic and severe nausea and vomiting, the plaintiff had to stop working. As such, she filed a claim for disability benefits under the “Reed Elsevier, Inc. Plan” administered by UNUM. Under the plan, the plaintiff was entitled to 6 months (28 weeks) of short term disability (STD) benefits and which the plaintiff did receive in full from UNUM.
The plaintiff, on April 14th 2008, began to receive her long term disability (LTD) benefits from UNUM until February 14th 2010. In a letter dated February 22nd 2010, the plaintiff was informed by UNUM that it was denying the plaintiff continued access to LTD benefits. The denial for LTD benefits was based on a Peer Review conducted by a certain Peter Kouros M.D. Prior to the Peer Review; UNUM had sent one of their representatives to the plaintiff’s home in May 2009 and completed a report which contained some “dubious assessments” about the plaintiff. Because the background of the “representative” was not known, the plaintiff is not sure whether the “representative” was qualified to make those “dubious assessments”.
The plaintiff, having retained the services of her Ohio disability lawyer, then appealed to UNUM’s decision to deny her LTD benefits on August 13th 2010. Together with her appeal, the plaintiff included an extensive appeal letter, a deposition transcript, medical records, a video statement and a vocational assessment supporting the plaintiff’s appeal. Nevertheless, UNUM denied the plaintiff’s appeal on October 8th 2010. The letter at the same time also indicated that the plaintiff had exhausted all her administrative remedies.
The Basis for the lawsuit against UNUM
Because the plaintiff had exhausted all her administrative remedies, she filed a lawsuit against UNUM’s decision to deny her LTD benefits due to the following:
- UNUM “failed to exercise the statutorily required duty of care and prudence” in administrating the plan solely for the plan’s beneficiaries and participants.
- UNUM was selectively reviewing and ignoring documents hence failing to provide a full and fair review of the plaintiff’s claim.
- UNUM was operating under an inherent conflict of interest as the claims adjuster and as a payer of benefits.
- Although UNUM has the authority in making claims determination, the language of the plan did not give sufficient deference to UNUM and hence the benefit determination must be made “de novo”. (De Novo is a legal term used to describe a situation of “Considering the matter anew, the same as if it had not been heard before”).
- While the plaintiff has exhausted all her administrative remedies, UNUM still continued to deny the plaintiff her LTD benefits.
Relief sought by the Plaintiff in the Lawsuit
Due to the above mentioned reasons, the Plaintiff seeks the following relief through the Court:
- Ordering UNUM to account and pay the disability benefits to the plaintiff in an amount equal to the contractual amount which the plaintiff is entitled to.
- An award of prejudgment interest
- Clarify the rights of the plaintiff under the plan
- Order UNUM to continue paying LTD benefits to the plaintiff
- An Award of attorney fees and costs
- Other relief which the plaintiff may be entitled to