Welch v. UNUM Life Insurance Co. of America

382 F.3d 1078, 33 Employee Benefits Cas. (BNA) 1871, 2004 U.S. App. LEXIS 18507, 2004 WL 1941299
CourtCourt of Appeals for the Tenth Circuit
DecidedSeptember 1, 2004
Docket02-3220
StatusPublished
Cited by29 cases

This text of 382 F.3d 1078 (Welch v. UNUM Life Insurance Co. of America) is published on Counsel Stack Legal Research, covering Court of Appeals for the Tenth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Welch v. UNUM Life Insurance Co. of America, 382 F.3d 1078, 33 Employee Benefits Cas. (BNA) 1871, 2004 U.S. App. LEXIS 18507, 2004 WL 1941299 (10th Cir. 2004).

Opinion

HENRY, Circuit Judge.

Plaintiff-appellee Kathy A. Welch was an employee of the Coleman Company and was eligible for coverage under Coleman’s long-term disability (“LTD”) insurance plan. Coleman’s plan was issued and administered by defendant-appellant UNUM. Ms. Welch suffers from fibromyalgia and went on disability leave on January 31, 1998. At the time she submitted her claim, the LTD plan provided for benefits until Ms. Welch turned sixty-five, and in no case less than sixty months. In August 1998, UNUM and Coleman amended the LTD plan through “Amendment 23,” which replaced the old plan with a new plan and which contained a 24-month limitation period for payments on “disabilities, due to sickness or injury, which are primarily based on self-reported symptoms.” Aplt’s App. vol. I, at 143. The effective date of Amendment 23 was retroactive to January 1, 1998, and it stated that “[c]laims for disabilities that occur prior to January 1, 1998 [would] be determined according to the policy(ies) in effect prior to this amendment.” Id. at 118. Subsequent to the enactment of Amendment 23, UNUM *1080 notified Ms. Welch that her long-term disability benefits would only be paid through July 29, 2000, because her disability qualified under the amended plan’s “self-reported symptoms” limitation.

In September 2000, Ms. Welch filed suit against UNUM, seeking a declaration that she is entitled to LTD benefits under the pre-amendment plan (“the initial plan”), not the post-amendment plan (“the new plan”). She also argued that even if the court should decide that the new plan controls, her condition of fibromyalgia does not fall within the self-reported symptoms limitation.

Ms. Welch and UNUM both filed motions for summary judgment, and the magistrate judge granted Ms. Welch’s motion and denied UNUM’s. The magistrate judge found that the LTD plan provided that benefits would vest upon the plan’s termination and that Amendment 23 caused the initial plan to terminate. Therefore, the magistrate judge found that UNUM could not retroactively apply Amendment 23 to deprive Ms. Welch of vested benefits, and he ordered that UNUM pay her benefits in accordance with the initial plan. UNUM now appeals. Because we disagree with the lower court that Amendment 23 caused the plan to terminate, we reverse and remand.

I. BACKGROUND

At all pertinent times, Ms. Welch was an employee of the Coleman Company. On March 1, 1979, Coleman entered into an agreement with UNUM to provide LTD insurance for all full-time employees. Ms. Welch became eligible for this insurance on September 11,1980.

Prior to the enactment of Amendment 23 in August 1998, the LTD plan provided that for an employee who became disabled before the age of sixty, the maximum benefit period was until age sixty-five, but not less than sixty months. Aplt’s App. vol. I, at 49. This initial plan contained a termination provision which stated, “[germination of this policy under any conditions will not prejudice any payable claim which occurs while this policy is in force.” Id. at 63. It also contained a provision stating that the “policy may be changed in whole or in part.” Id. at 65.

On January 31, 1998, Ms. Welch became disabled, claiming that she was no longer able to work due to fatigue, joint pain, and headaches. On or about July 23, 1998, UNUM received Ms. Welch’s claim for LTD benefits. She reported that she was unable to work due to chronic pain and extreme fatigue. Ms. Welch was diagnosed with fibromyalgia, which is a “chronic pain disorder” characterized by “[widespread musculoskeletal pain and excess tenderness” and fatigue. Id. at 317-18.

In a letter dated September 25, 1998, UNUM notified Ms. Welch that her claim for disability benefits had been approved retroactive to July 30, 1998. Id. at 161. The LTD plan provides for a 180-day elimination period, which is a “period of consecutive days of disability for which no benefit is payable. The elimination period ... begins on the first day of disability.” Id. at 52. Because Ms. Welch became disabled on January 31, 1998, her elimination period did not conclude until July 29, 1998. The letter also gave an explanation of how Ms. Welch’s benefits were calculated and when to expect monthly benefits checks, as well as notice that ongoing benefits were conditioned upon her ability to meet the definition of disability and that the maximum period of payment was to age sixty-five. Id. at 161-62.

On August 6, 1998, the LTD plan was amended by UNUM and Coleman. The amendment, referred to as Amendment 23, stated that “[t]he entire policy is replaced *1081 by the policy attached to this amendment.” Id. at 118. Amendment 23 contained a twenty-four-month limitation period for payments on “disabilities, due to sickness or injury, which are primarily based on self-reported symptoms.” Id. at 143. Amendment 23 defined “self-reported symptoms” as

the manifestations of your condition which you tell your doctor, that are not verifiable using tests, procedures, or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy.

Id. at 144. Amendment 23 provided that “[t]he effective date of these changes is January 1, 1998.” Id. at 118. Claims for disabilities which occurred prior to that date were to be determined according to the initial plan, while claims for disabilities which occurred after that date were to be determined with reference to Amendment 23. Id.

On April 23, 1999, UNUM wrote to Ms. Welch about the status of her LTD claim. Id. at 170-71. The letter informed her that her benefits, assuming her condition remained the same, would only be paid through July 29, 2000. Id. The letter explained that the plan under which UNUM would be providing benefits had a twenty-four-month limitation for disabilities based on self-reported symptoms and that the medical information contained in Ms. Welch’s file with UNUM indicated that her disability fell within the limitation. Id.

On September 17, 1999, Ms. Welch requested UNUM to reconsider its decision to limit her benefits pursuant to the “self-reported symptoms” limitation. Id. at 328-331. She asserted that this limitation was not included in the plan summary available to Coleman or to her at the time she left Coleman and thus should not be applied to her. Id. Ms. Welch also disputed UNUM’s position that her illness was not verifiable, and she enclosed copies of medical records from November 1992, January 1995, July 1997, and June 1999, as well as copies of letters from her doctor. Id.

In a letter dated November 12, 1999, UNUM advised Ms. Welch that it had reviewed the information she had provided, along with the medical records previously contained in her file. Id. at 337-38. However, UNUM stated that Ms.

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Bluebook (online)
382 F.3d 1078, 33 Employee Benefits Cas. (BNA) 1871, 2004 U.S. App. LEXIS 18507, 2004 WL 1941299, Counsel Stack Legal Research, https://law.counselstack.com/opinion/welch-v-unum-life-insurance-co-of-america-ca10-2004.