Lyman v. Unum Grp.

378 F. Supp. 3d 81
CourtDistrict Court, District of Columbia
DecidedMay 10, 2019
DocketCIVIL ACTION NO. 17-11530-JGD
StatusPublished

This text of 378 F. Supp. 3d 81 (Lyman v. Unum Grp.) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lyman v. Unum Grp., 378 F. Supp. 3d 81 (D.D.C. 2019).

Opinion

We received her completed claim on March 23, 2016. According to the Notice of Proof of Loss provisions in the policy (outlined below), her claim should have been received no later than February 27, 2016. Because we did not receive Ms. Lyman's claim by this date, we are unable to give consideration to her claim and benefits will not be payable. Her claim has been closed.

(Id. ).

Unum revised the letter denying Ms. Lyman LTD benefits twice. (PF ¶ 43). On June 23, 2016, Unum sent a letter to Ms. Lyman's attorney noting several changes to the decision, including the following:

• Unum had received Ms. Lyman's completed claim on June 20, 2015 and not on March 23, 2016.
• According to the Provision, Unum stated it should have received the claim no later than February 27, 2015 as opposed to February 27, 2016.

(AR VI: CL-LTD-1015). Unum then sent another letter on June 27, 2016 once again correcting the dates included in their reasoning for the LTD benefits denial. Unum's corrected letter reads:

We received her completed claim on June 16, 2015. According to the Notice and Proof of Loss provisions in your policy (outlined below) the claim should have been received no later than March 21, 2015. Because we did not receive your claim by this date, we are unable to give consideration to the claim and benefits will not be payable.

(Id. at CL-LTD-1024) (emphasis omitted).

E. Appeals

While the LTD claim was pending, on March 23, 2016, Ms. Lyman appealed the STD decision. (DF ¶ 14; PF ¶ 39; AR II: CL-STD-441-42; AR III: CL-STD-633). In *89the appeal letter, Ms. Lyman's attorney wrote, in part:

Unum terminated Ms. Lyman's claim on the basis that she was not insured under the terms of the Plan when she ceased work. This is incorrect, and is directly contradicted by the information contained in Unum's file, including without limitation, confirmation from Ms. Lyman's employer as to her date of disability and her last date worked.

(AR II: CL-STD-441).

In a letter dated June 27, 2016, the same day Unum sent the second amended denial letter for Ms. Lyman's LTD claim, Unum rendered a decision on Ms. Lyman's appeal of STD benefits. (AR III: CL-STD-753-58). Unum informed Ms. Lyman's attorney that the STD claim had been incorrectly denied for lack of coverage, but it was still denied because, like Ms. Lyman's LTD claim, it was not filed on time. (DF ¶ 15; PR ¶ 15; AR III: CL-STD-754). Unum provided that:

It was determined that your client did not submit her claim within the required timeframes as specified by the policy.
Because a new basis for denial is being cited, you and your client will be provided new appeal rights.
... your client's claim was initially denied by the Benefits Center citing her coverage ended on June 24, 2014. The appeal review did not address the coverage issue or if your client satisfied the definition of disability. During the appeal review, Unum recognized that your client's claim was submitted late. Outlined below are Unum's findings as it relates to the late filing.
The Short Term Disability file reflects an Attending Physician's Statement was received on June 16, 2015.
On July 15, 2015, your client submitted an Employee Statement, completed by her on July 14, 2015. She provided a last date of work of June 24, 2014.
On August 14, 2015, Unum received the Employer's Statement, which noted her date last worked of June 25, 2014. It was confirmed on September 29, 2015 that she resigned from Revere Public Schools on June 24, 2014.
Your client was notified on October 1, 2015 that her claim for Short Term Disability benefits could not be approved as she had resigned on June 24, 2015,7 was not on an approved leave of absence, and her STD coverage ended as of her resignation date.
You appealed the decision in your letter of March 23, 2016 and requested an extension of 45 days to provide additional information before the appeal review began. It was agreed that the Short Term Disability appeal review would be pended following completion of your client's Long Term Disability claim.
On June 14, 2016, The Benefits Center notified you of the determination that Long Term Disability benefits would not be approved. An appeal review of your client's Short Term Disability claim was initiated following communication of the Long Term Disability determination. During the appeal evaluation, we determined your client's claim was submitted beyond the policy timeframes.
Your client submitted her claim form on July 15, 2015 stating she last worked on June 24, 2014. The Employer's Statement, received on August 14, 2015, reflects *90your client last worked on June 25, 2014.
The Short Term Disability policy states Notice and Proof of Loss should be sent within 30 days after your client's disability begins, however, she must send Unum written proof of her claim no later than 90 days after her elimination period.
The Short Term Disability elimination period is 30 days for disability due to an injury or a sickness. The 30-day elimination period would have ended on July 25, 2014. 90 days following the elimination period is October 23, 2014.
Therefore, Unum should have received your client's Short Term Disability claim no later than October 23, 2014. Unum did not receive notice of her claim until June 16, 2015, when the Attending Physician's Statement was received.
Because your client's Short Term Disability claim was not submitted within the time frames outlined by the policy, payment of benefits cannot be considered.

(AR III: CL-STD-754-55).

On December 14, 2016, Ms. Lyman filed an administrative appeal of the LTD decision. (PF ¶ 46; AR VI: CL-LTD-1043 ("Pursuant to the terms of Unum Group's [ ] June 27, 2016 letter, I am writing to appeal Unum's decision to uphold its termination of Ms. Lyman's claim for long-term disability and life insurance waiver of premium benefits" (emphasis omitted))).8

As part of her appeal, Nany Lyman submitted an affidavit. (AR III: CL-STD-818-21). Therein, she explains in detail the medical complications which prevented her from continuing to teach and from readily filing a claim. She states in part:

I resigned from teaching at the end of the 2014 school year because I could no longer function effectively as a teacher. For about seven years, headaches had increasingly intruded on my professional and personal life to the point that I always suffered headache pain. Arthritis and bulging discs in my neck, combined with stress, triggered constant pain that was distinguishable only by degree. To complicate matters, I was also diagnosed with clinical depression so that a cycle of headaches and depression became so debilitating that I was often absent at work, absent enough to be alternately judged, spoken to, warned, and docked pay.

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Bluebook (online)
378 F. Supp. 3d 81, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lyman-v-unum-grp-dcd-2019.