Recently a lawsuit was filed at the District Court for the Central District of California by a former employee of St. Agnes Medical Center through a California disability attorney against the Unum Life Insurance Company of America (Unum) for breach of the Employee Retirement Income Security Act of 1974 (ERISA). In the case of Carolyn Jacks vs. Trinity Health Plan and Unum Life Insurance Company of America, the plaintiff Carolyn Jacks alleged that Unum had erroneously and wrongfully denied her claim for long term disability (LTD) benefits under the Trinity Health Plan.
The Alleged Facts of the Case
According to the Unum lawsuit, the plaintiff stated that she was a participant in an employee welfare benefit plan called the “Trinity Health Plan” (the LTD Plan) established by her former employer, the St, Agnes Medical Center. Under the LTD Plan, the plaintiff is entitled to disability benefits in the event she became disabled as defined by the terms of the LTD plan.
Unum, meanwhile, acted as the Plan Administrator for the disability Plan. Unum is also alleged to be the Claims Administrator for the LTD Plan. The plaintiff claimed that because Unum acts as the decision maker and payer of disability benefits, it is operating under an inherent conflict of interest while administering claims and this conflict of interest affected the claims determination.
Alleged Legal Basis for Legal Action against Unum
The plaintiff contended in the lawsuit that she was, at all relevant times, a covered participant for the LTD Plan that was administered by Unum for the St, Agnes Medical Center. During the course of the plaintiff’s employment, she became disabled under the terms of the LTD Plan.
Subsequently, the plaintiff filed a claim with Unum for LTD benefits under the above mentioned plan. However, on October 10th 2010, Unum denied the plaintiff her claim LTD benefits on the basis that her claims application submitted three months after it was supposedly due resulting in claim being prejudicial to Unum. Unum at the same time also argued that the plaintiff was not disabled within the terms of the LTD Plan.
Consequently, the plaintiff filed an appeal to Unum’s determination to deny her claim for LTD benefits. The plaintiff alleged that despite overwhelming evidence of a valid claim, Unum had erroneously and wrongfully continued to uphold its prior determination to deny the plaintiff’s claim.
As such, the plaintiff argued that Unum had breached and violated the provisions of ERISA, specifically in the following respects:
- Failure to provide LTD benefit payments to the plaintiff when the plaintiff is disabled and entitled to LTD benefits under the LTD Plan.
- Failure to provide a timely and reasonable explanation of the grounds that Unum relied on upon for the denial of the plaintiff’s claims for LTD benefits.
- Failure to describe to the plaintiff the additional material or information required for the plaintiff to perfect her appeal after denying her claim and an explanation why such material was necessary.
- Failure to investigate properly the plaintiff’s disability claim.
- Failure to provide a full and fair review of the plaintiff’s disability claim.
Request for Relief
As a result of the Unum wrongful determination of her claim for LTD benefits, the plaintiff alleged that she had suffered damages and seeks the following relief from the Court:
- An award of disability benefits due the plaintiff.
- A declaration that the plaintiff is entitled to immediate reinstatement to the LTD Plan with all the benefits to which she is entitled to under the LTD Plan.
- Or alternatively remand the plaintiff’s claim to the claims administrator of the LTD Plan for a proper and fair review to the extent that all new facts or submissions are to be considered.
- An award of attorneys’ fees and costs.
- An award of prejudgment and postjudgment interest as permitted for under ERISA.
- Any other relief deemed just and proper by the Court.