The U.S. Court of Appeal for the Eleventh Circuit recently reversed the decision of a federal district court affirming Unum Life Insurance Company of America’s (“Unum”) decision to terminate a former pharmacist’s long-term disability benefits. The plaintiff beneficiary in the case was employed as a pharmacist from 1996 until 2016, when she suffered an accident at work that injured her back. The plaintiff suffered severe back injuries, and she tried several treatments and medications for her pain. The one that worked best was gabapentin, a medicine that left her with some cognitive defects.

Unum paid two years’ worth of benefits, but it terminated benefits when the policy definition of “disabled” changed from the inability to perform one’s own occupation to the inability to perform any gainful occupation. Unum’s retained reviewing physician found that the plaintiff’s reported activities, including the use of a computer and management of her finances, meant she could not have a “functionally relevant cognitive impairment.” The Court found that Unum’s decision to terminate benefits was wrong even under a deferential abuse of discretion review. The court found that “Unum arbitrarily rejected” the plaintiff’s evidence of “cognitive impairments that rendered her unable to perform any gainful occupation for which she is ‘reasonably fitted by education, training, or experience,’” as stated in the Unum policy.

The plaintiff’s success in this case, Sisung v. Unum Life Ins. Co. of Am, No. 21-11593, _F. App’x_, 2022 W 1772273 (11^th Cir. Jun 1, 2022), was due in large part to the fact that the plaintiff packed the record with evidence during the administrative appeal process. This gave the court evidence to go by in making a decision for plaintiff. Had the plaintiff failed to introduce evidence during the appeal process of her cognitive impairment, she likely would not have won.

Retaining an attorney for an ERISA appeal and possible lawsuit is a smart decision. The decision in the Sisung case turned heavily on the language of the policy, and result assured the policy was written by an attorney. Also, gathering and submitting all relevant medical evidence during the appeal process is extremely important. The Pellegrin Firm is a law firm in Metairie, Louisiana, that represents beneficiaries in ERISA long-term disability appeals and lawsuits. The Pellegrin Firm represents people throughout the New Orleans area and throughout the State of Louisiana. The Pellegrin Firm can be reached at 504-405-3245 or via email at info@pellegrinfirm.com.