ERISA; self-reported symptoms limitation
The failure to include a self-reported symptoms limitation in the summary plan description (“SPD”) prevents an ERISA plan from relying on it to discontinue benefits.
“Here, the SPD clearly sets out that long-term benefits will be discontinued after twenty-four months if a participant’s disability is due to mental illness or substance abuse. It does not, however, mention that this same time limitation applies if a participant’s disability is based primarily on self-reported symptoms. This omission violates § 1022. Unum proffers no reason, and none is apparent, for its highlighting the loss of benefits that results from the application of the mental illness and substance abuse limitations in three different places in the SPD while omitting the self-reported symptoms limitation, which is part of the same provision in the plan. The self-reported symptoms limitation is not an idiosyncratic contingency concerning only a few people but rather a broad exception to the continuation of benefits that should reasonably be included in the SPD. See Bowerman, 226 F.3d at 590-91 (‘In this case, the information the Plan should have provided to Ms. Bowerman would not have been information unique to her situation; rather, the information she needed would have been information relevant to all Plan participants who were rehired by Wal-Mart within a few weeks or months after leaving the company. The Plan’s explanation of its policy in the 1995 SPD simply failed to fully and fairly communicate how the policy would work to the benefit of any of the Plan’s participants who found themselves in such circumstances.’); cf. Herrmann, 978 F.2d at 983- 84 (finding no § 1022 violation where the limitation that was omitted from the SPD would affect only a few people); Tegtmeier v. Midwest Operating Eng’rs Pension Trust Fund, 390 F.3d 1040, 1048 (7th Cir. 2004) (same).”
Affirmed in part, and Reversed in part.
10-3898 & 11-1006 Weitzenkamp v. UNUM Life Ins. Co. of America
Appeals from the United States District Court for the Eastern District of Wisconsin, Griesbach, J., Lefkow, J.