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Claim of Incapacity Insufficient to Overcome Late Filing – D. Ma.

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  • Claim of Incapacity Insufficient to Overcome Late Filing – D. Ma.

    Claim of Incapacity Insufficient to Overcome Late Filing – D. Ma.

    Attached is a case out of the District of Massachusetts, Lyman v. Unum Group, et. al. In the case, plaintiff seeks ERISA governed short term and long term disability benefits. Plaintiff ceased working on June 24, 2014. Pursuant to the terms of the plan, she was required to file a short term disability claim by October 23, 2014 and a long term disability claim by March 22, 2015. The policy stated that “if it is not possible to give proof within 90 days it must be given no later than 1 year after the time proof is otherwise required except in the absence of legal capacity.” The earliest date that Plaintiff filed her claim was in June 2015. Defendant denied plaintiff’s claim as untimely.

    Plaintiff argued, in part, that she was legally incapacitated due to her medical conditions and unable to file the claim within the initial 90 days and, therefore, her claim should be accepted as it was filed within 1 year and 90 days of her date of disability. The court found that Unum did not abuse its discretion in determining that she should have been able to file a claim within 90 days of her date of disability.

    The record further establishes that Unum did not abuse its discretion in finding it was possible for Ms. Lyman to file a timely claim despite her medical condition. Ms. Lyman argues that “[her] medical condition prevented her from filing her disability claims in the 90-Day Period, as [she] explained to Unum during her August 13, 2015 call [], her April 27, 2016 call [] and in her statements provided to Unum.” (Lyman Reply at 7). Ms. Lyman argues that in the context of those statements and the expansive medical record otherwise before Unum at the time, Unum was wrong to deny her the extra time to file. This court finds that although Unum had extensive evidence of Ms. Lyman’s condition, its decision that it was possible for Ms. Lyman to file on time was reasoned and supported by substantial evidence.

    Unum considered Ms. Lyman’s medical records when it made its initial decision and when conducting its internal appeal. Unum documented the medical information Ms. Lyman provided in various phone calls and letters. (See AR II: CL-STD-58; AR IV: Cl-LTD-0433). Unum ultimately decided that Ms. Lyman “did not file her STD and LTD claims in a timely manner consistent with the notice and proof provisions of the policies. The reasons she gave for her late filing were not reasonable.” (AR III: CL-STD-965). Unum provided a number of reasons for its decision. Unum explained therein that it had reviewed forms from Dr. Witts, Dr. Hammer and Ms. Lyman claiming Ms. Lyman suffered from chronic headache, neck pain, major depressive disorder, agoraphobia, and social phobia. (Id.). In its letter denying both appeals, Unum acknowledged that in connection with the appeals Ms. Lyman submitted additional medical records. (Id.). Unum acknowledged Ms. Lyman’s representation that she has difficulty filling out forms, and refused to accept that reason for late filing. (See id. at CL-STD-966 (“Ms. Lyman was a teacher, and it is not reasonable that she would have been unable to complete a claim form within 90 days of the end of the elimination period in the policies or provide an APS form to her physician.”)). Unum then explicitly recognized Ms. Lyman’s argument that her medical condition prevented a timely filing. (Id. (“You have stated on appeal that Ms. Lyman’s medical condition prevented her from filing a timely appeal. I have reviewed the available medical records and noted the following . . .”)). Unum then extensively quotes from Ms. Lyman’s medical records.

    In quoting from Ms. Lyman’s medical records in its written appeal decision, Unum quoted portions of the records which discuss Ms. Lyman’s activities and professional plans as opposed to her diagnoses or certain symptoms. (e.g. id. at CL-STD-966 (“Dr. Hammer’s July 23, 2014, office visit note stated Ms. Lyman had left her job due to an inadequate teaching license with new requirements. She felt it was too stressful teaching ESL students (English as a second language), especially with her health problems. Her finances were uncertain and she was looking into other jobs, for example, a job with the State. She was contemplating visiting her sister and brother-in-law in Illinois, who had been in a terrible motor vehicle accident.”)). Relying on these statements, Unum rejected Ms. Lyman’s argument that her medical condition prevented her from filing on time. Unum provided:

    You state her medical condition prevented her from filing the claims sooner. Her employer has indicated she was not on a leave of absence, and had not applied for a leave of absence in June 2014. During the period in question, she was able to apply for unemployment benefits at some point prior to Dec. 2, 2014. Her doctors’ office visit notes indicate she was looking for and applying for jobs outside of teaching. At some time between July 23, 2014, and Oct. 7, 2014, she spent a month in Illinois providing assistance to her sister, brother-in-law and nephew due to the sister and brother-in-law having been seriously injured in a car accident. She later reported she flew there, so she was able to plan the trip and negotiate travel through airports. These activities are not consistent with a person who lacked legal capacity to file her claims in a timely manner. There is no indication it was not possible for her to provide notice and proof of claim within the timeframes specified by the policies.

    ... You have stated on appeal that Unum failed to provide a full and fair review of Ms. Lyman’s claims, in violation of ERISA regulations, because Unum did not consider her symptoms and functional limitations given her occupation, and that Unum did not consider her as a whole person when taking into account the impact her conditions have on her ability to perform the duties of her occupation.

    You are correct in stating that Unum did not evaluate the medical and vocational components of the claim to determine whether or not Ms. Lyman was disabled, as defined by the policies. However, Unum did not violate ERISA regulations. Ms. Lyman did not file her claims in a timely manner consistent with the requirements under the policies. Because the claims were filed late, Unum is not required to determine whether or not Ms. Lyman was disabled. The state of Massachusetts does not require Unum to prove it was prejudiced by the late filing.

    Based on the above, we have determined Ms. Lyman’s claims were filed late. Her reasons for the late filing were not reasonable, and she has not provided evidence to support it was not reasonably possible for her to file her claims in a timely manner. The decision to deny her STD and LTD claims was appropriate.

    (Id. at CL-STD-968). However, the existence of contrary information does not make an otherwise reasonable decision by Unum an abuse of discretion. The record establishes that Unum properly considered all of the evidence before it. It did not selectively pick facts from the record in order to support its conclusion. See Conrad v. Reliance Std. Life Ins. Co., 292 F. Supp. 2d 233, 238 (D. Mass. 2003) (finding decision unreasonable where it relied on a doctor’s conclusions which “select[ed] for emphasis just one or two elements of a medical report, while ignoring additional facts and important context”). See also Al-Abbas v. Metro. Life Ins. Co., 52 F. Supp. 3d 288, 296 (D. Mass. 2014) (Holding that while “the mere existence of contrary evidence in the record is not sufficient to render a determination arbitrary and capricious . . . a plan administrator may not ‘simply ignore contrary evidence, or engage with only that evidence that supports his conclusion.’” (citing Petrone v. Long Term Disability Income Plan for Choices Eligible Emps. of Johnson & Johnson & Affiliated Cos., 935 F. Supp. 2d 278, 293 (D. Mass. 2013))). Although Ms. Lyman’s condition certainly appears to have made it difficult to perform certain tasks, a wholistic view of the record shows that Unum was not unreasonable in determining it was possible for her to file on time. (See AR II: CL-STD-64, 130-31). It was Unum’s responsibility to evaluate these records, which it expressly did. (See, e.g., AR II: CL-STD58-59).

    Ms. Lyman additionally argues that Unum failed to understand the record before it, and that “Unum missed the connection between what Ms. Lyman hoped she would be able to do, and the reality of her medical condition, which made this expectation impossible.” (Lyman Reply at 11). Unum considered but rejected this argument. (AR III: STD-CL-966 (“She stated she did not think her condition would last this long and she thought she would be able to return to work. This is not a reasonable basis for not filing a timely claim.”)). It was not an abuse of discretion for Unum to require Ms. Lyman to comply with the filing obligations even if she hoped her condition would improve. See Monast v. Johnson & Johnson, 680 F. Supp. 2d 299, 304 (D. Mass. 2010) (“. . . if the ERISA plan expressly provides that its members are obligated to [act], we do not think it can be considered ‘unfair’ to require plan members to abide by the agreement.” (quoting Harris v. Harvard Pilgrim Health Care, Inc., 208 F.3d 274, 279 (1st Cir. 2000))). More importantly, Unum considered what Ms. Lyman actually did when determining that filing the application was among the items she could have accomplished. Unum was not mislead by Ms. Lyman’s high aspirations. In sum, Unum fully evaluated Ms. Lyman’s arguments and made a reasoned decision supported by evidence that it was possible for her to file on time.
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