Weitzenkamp v. Unum Life Ins. Co. of America
661 F.3d 323
7th Cir.2011Background
- Weitzenkamp was covered by an ERISA long-term disability plan administered by Unum, with discretion given to Unum to determine eligibility.
- The plan provides a self-reported symptoms limitation for disabilities primarily based on self-reported symptoms, expiring after twenty-four months, especially for mental illness or substance abuse.
- The SPD did not mention the self-reported symptoms limitation, creating a potential mismatch between plan terms and what participants were told.
- Unum initially approved long-term disability benefits, then later discontinued them after twenty-four months, applying the self-reported symptoms and mental-illness limitations.
- Weitzenkamp retroactively received Social Security benefits, triggering Unum’s right to recover overpayments; approximately $9,089 remained unrecovered.
- The district court found the termination of benefits arbitrary and capricious to the extent based on lack of disability, but upheld the application of the self-reported symptoms limitation; it also held that Unum could recover the overpayment.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the SPD omission estops reliance on the self-reported limit | Weitzenkamp argues SPD omission bars denial | Unum contends omission does not bar reliance | SPD omission estops reliance on the self-reported limit |
| Whether § 207(a) precludes recovery of overpayments | Weitzenkamp asserts SSA protection applies | Unum contends overpayments may be recovered from plan funds | § 207(a) does not bar recovery of overpayments |
| Appropriate remedy for ERISA denial after remand or reinstatement | Reinstatement appropriate based on record of disability | Remand or alternative relief possible; cross-appeal improper | Reinstatement of benefits retroactive to August 22, 2008 is appropriate |
Key Cases Cited
- Mers v. Marriott Int'l Group Accidental Death & Dismemberment Plan, 144 F.3d 1014 (7th Cir. 1998) (ERISA plan terms and § 1022 estoppel if SPD omits material terms)
- Bowerman v. Wal-Mart Stores, Inc., 226 F.3d 574 (7th Cir. 2000) (SPD disclosures must fairly communicate plan terms)
- Herrmann v. Cencom Cable Assocs., Inc., 978 F.2d 978 (7th Cir. 1992) (SPD must be sufficiently accurate and comprehensive)
- Tegtmeier v. Midwest Operating Engineers Pension Trust Fund, 390 F.3d 1040 (7th Cir. 2004) (ERISA disclosure requirements and plan interpretation considerations)
- Holmstrom v. MetLife Ins. Co., 615 F.3d 758 (7th Cir. 2010) (evidence-based approach to disability determinations under ERISA)
- Sereboff v. Mid Atl. Med. Servs., 547 U.S. 356 (U.S. 2006) (plan beneficiary recoveries from the plan assets under reimbursement clause)
- Gutta v. Standard Select Trust Ins. Plan, 530 F.3d 614 (7th Cir. 2008) (recognition of reimbursement claims under ERISA plans)