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This month’s Friday Five explores decisions reviewing what evidence is necessary to prove that a condition like long COVID is “sufficiently disabling”, what standard of review applies to benefits under FEGLI, whether an insurer can seek to uphold its denial decision in court based on a reason it did not provide in its initial denial decision, whether a plaintiff must show the specific cause of her symptoms, and whether a plan is preempted by ERISA when it is completely voluntary and all the employer does is market it and deduct payroll. All in all, the policy language controls.
The Saul Ewing ERISA Litigation Team
- Is it an abuse of discretion for a provider to require objective evidence that a condition like long COVID is “sufficiently disabling” in order to award long term disability benefits? No, says the District Court for the Eastern District of Pennsylvania. Plaintiff, a former river pilot, filed a complaint against Unum alleging Unum wrongfully denied him long term disability benefits under his plan. The parties both moved for judgment on the administrative record. Plaintiff argued that he had provided sufficient evidence to support “his disability from his regular occupation,” and Unum ignored this evidence, making its denial arbitrary and capricious. Unum argued that it thoroughly evaluated the evidence, including obtaining four peer reviews and two vocational experts, and correctly concluded that Plaintiff had not provided sufficient evidence to support this disability. The court first decided that it would review Unum’s decision, as the claims fiduciary under the relevant Plan, under an arbitrary and capricious standard. Next, the court reviewed Unum’s formulation of Plaintiff’s ‘regular occupation,’ as defined by the plan. The court held that the definition in the group policy controlled the outcome, and the group policy defined ‘regular occupation’ as “how the work tasks are performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific occupation.” Thus, Unum’s decision to define Plaintiff’s “regular occupation as performed in the national economy is a ship pilot requiring light duty rather than a composite ship pilot and deckhand” was not arbitrary and capricious. The court then turned to whether Unum’s insistence on objective evidence in reviewing the extent of Plaintiff’s disability was arbitrary and capricious. The court said that while “Unum may not insist on objective evidence of long COVID and a decision to deny benefits based on the lack of objective evidence of the diagnosis is arbitrary and capricious[,]…it is not an abuse of discretion to require objective evidence of a condition, like chronic fatigue syndrome and fibromyalgia, is ‘sufficiently disabling to warrant an award’ of long term disability benefits.” Thus, the court approved Unum’s evaluation of “objective evidence of [Plaintiff’s] functional limitations resulting from long COVID.” Finally, the court held that there was no structural conflict rendering Unum’s decision arbitrary and capricious because Plaintiff had only showed generic evidence of Unum’s “past unfair claim practices” rather than any procedural problems in the instant case. Ryan Hans v. Unum Life Ins. Co. of America, Civ. No. 25-3595, 2026 WL 116487 (E.D. Pa. Jan. 15, 2026).
- What standard of review applies to an insurer’s decision to deny accidental death benefits under Federal Employee’s Group Life Insurance Act of 1954 (“FEGLI”)? Arbitrary and capricious, holds the Eleventh Circuit Court of Appeals. In reviewing a district court’s order on the parties’ judgment as a matter of law, the Eleventh Circuit affirmed the district court’s decision, but stated that the unique ERISA inquiry previously developed by the Eleventh Circuit, which the district court had applied, was not necessary to review an accidental death denial under a FEGLI policy. The Eleventh Circuit held that, under the specific policy language, the insurer’s “decision about a claimant’s entitlement to benefits ‘is to be given full force and effect, unless it can be shown that the determination was arbitrary and capricious.’” The Eleventh Circuit saw “no reason to import our lengthy and sometimes confusing ERISA framework into FEGLI cases. That’s especially true since the insurance contract itself calls for arbitrary-and-capricious review.” On the merits of the denial, Plaintiff died after she fell out of her vehicle and was not able to recover from surgery. The autopsy noted that the leg injury was “likely responsible for the final event,” but also emphasized Plaintiff’s “history of ‘underlying interstitial lung disease.’” MetLife awarded Plaintiff’s daughter’s request for life insurance benefits but denied the daughter’s request for “accidental death and dismemberment insurance.” The Eleventh Circuit held that MetLife’s decision to deny accidental death benefits was not arbitrary and capricious because, under the specific language in the policy, Plaintiff’s death was not ‘solely’ the result of her injury. The court reasoned ‘[b]ecause ‘solely modifies ‘injuries,’ not ‘death’ the policy does not required the insured’s death to result ‘solely’ from an accidental injury–it requires the injury to be sustained ‘solely through violent, external, and accidental means.’” The Eleventh Circuit further noted that the claimant’s ‘death’ must be “the ‘direct result’ of the accidental injury.” The Eleventh Circuit held that while Plaintiff’s accident “obviously set off the chain of unfortunate events that ultimately led to her death[,]…it is equally obvious that her existing lung disease ‘contributed to it.’” Finney v. Metropolitan Life Ins. Co., No. 24-13140, 2026 WL 194048 (11th Cir. Jan. 26, 2026).
- Can an insurer rely on provision not raised in its initial benefit denial when the court reviews a case de novo? Yes, says the Distrct Court for the Northern District of Illinois. Plaintiff stopped working due to lingering back pain from a car accident. Unum initially paid Plaintiff long term disability benefits, but ended those benefits after the 180-day elimination period, noting that the “ frequency of treatments, which include follow up visits greater than 30 days apart does not support the presence of severe symptoms,’” and there was no further evidence that Plaintiff followed his doctor’s recommendations. The letter informing Plaintiff of this decision also relied upon the provisions of the plan which define “disabled” as including a requirement that a claimant must be under the regular care of a physician. Plaintiff appealed the denial of his benefits, and the parties filed cross-motions under Rule 52, asking the court to resolve the motions on the basis of the administrative record. In its motion, Unum argued that plaintiff failed to satisfy plan requirements because he was not regularly under the care of a physician. Plaintiff objected to this argument because Unum did not raise this issue in its initial denial of benefits. The court considered the argument because it was conducting a de novo review, and under Seventh Circuit precedent, the court can review “post hoc rationalizations.” The district court further noted under de novo review in the ERISA context “the district court must come to an independent decision on both the legal and factual issues that form the basis of the claim…[and] the district courts are not reviewing anything; they are making an independent decision about the employee’s entitlement to benefits. The court then reviewed the administrative record and found that Unum had properly denied Plaintiff’s long term disability benefits due to the fact that he was not disabled. The policy requires that a claimant be under regular care of a physician and there was evidence he had ceased care for at least nine months. McKenzie Jones v. Unum Life Ins. Co., NO. 24 C 3911, 2026 WL 96985 (N.D. Ill. Jan. 13, 2026).
- When policy language requires that disability must be “due to sickness or injury” must a plaintiff show the cause of each of her symptoms? The District Court for the Eastern District of Michigan says no. Plaintiff, a pediatric dermatologist, suffered from various symptoms resulting from the birth of her second child. Unum initially paid her long term disability benefits but denied those benefits after Unum determined she was no longer disabled under the policy. At the district court, on cross-motions for judgment based on the administrative record, Unum argued that Plaintiff was not disabled under her policies because she could not show a clear diagnosis for her symptoms, meaning she could not show that she was unable to perform her job duties due to sickness or injury. The court held that neither ERISA, nor Plaintiff’s plan required such a showing. Turning first to the language of the policy, the district court held that instead of requiring that the plaintiff show they have a sickness or injury, Unum should have required Plaintiff to show what caused her sickness or injury. The court held that the evidence must “show that an injury or sickness was the cause of a claimant’s limitations, even if it had not yet been determined which specific diagnosis was the cause of those limitations.” Further, the court pointed out that requiring objective medical evidence of a disability, as Unum reasonably can require, is different than requiring a plaintiff to show a definitive and final diagnosis or a clear etiology. Marla N. Jahnke M.D. v. Unum Life Ins. Co. of America, 799 F.Supp. 3d 628 (E.D. Mich. 2025).
- Does ERISA apply when a policy does not name a fiduciary, provide an amendment procedure, or identify any person with authority to amend? No, says the District Court for the Central District of California. Plaintiff purchased individual disability insurance through a licensed broker during his employment. That program expressly stated the policy was voluntary and not subject to ERISA. Plaintiff personally paid for all premiums from his pay check and the only involvement of Plaintiff’s employer was allowing Unum to provide marketing materials and processing payroll deductions. In response to Plaintiff’s lawsuit challenging the denial of his long term disability benefits, Defendants asserted ERISA preemption. The district court held that the plan did not meet the statutory requirement because it did not “identify a named fiduciary, does not provide a procedure for amending the plan, and does not identify any person who has authority to amend the plan.” Further, the court noted that the policy lacked “an employer administrative scheme” that would subject it to ERISA, finding that the employer “did [nothing] more than relay limited information about the insurance program to eligible employees and deduct premiums from the employees’ paychecks.” Finally, the court held that the Department of Labor’s Safe Harbor Regulations applied because 1) “[w]here an employer acts as a mere conduit for payment of premiums, the employer does not make contributions for purposes of the first safe harbor provisions[;]” 2) the policy language was clear that participation was completely voluntary, and 3) an objectively reasonable employee would not conclude that the employer had endorsed the policy. Jason T. Koo v. Unum Group; Provident Life and Accident Ins. Co., and Does 1-10, No. 2:25-cv-05797, 2025 WL 3687545 (C.D. Cal. Dec. 16, 2025).
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