United States District Court, D. Massachusetts
MEMORANDUM OF DECISION AND ORDER ON CROSS-MOTIONS FOR
Gail Dein, United States Magistrate Judge.
matter is before the court on cross-motions for summary
judgment by the plaintiff Nancy Lyman (“Ms.
Lyman” or the “plaintiff”) and defendants
Unum Group and Unum Life Insurance Company (collectively,
“Unum” or the “defendants”). Ms.
Lyman worked as a public school teacher in the Revere Public
Schools and for years paid premiums on short term and long
term disability insurance policies managed by Unum. After
leaving teaching, Ms. Lyman applied for both long term and
short term disability coverage under her policies. Unum
denied both claims as untimely. Ms. Lyman administratively
appealed those decisions, and the denials were upheld. Ms.
Lyman then filed for relief from this court.
the plaintiff and the defendants now move for judgment as a
matter of law. Ms. Lyman argues that Unum inconsistently
interpreted the language in her policies in denying her claim
as late. Alternatively, she argues that Unum’s
determination was unreasonable because under the language of
the insurance policies, if it was impossible for her to file
within the allotted time, she should have been given an extra
year to file her claims and Unum should have only denied her
claims as late if Unum was prejudiced by the late filing. Ms.
Lyman argues that it was impossible to file on time because
of misrepresentations that Unum made to her and because of
her medical condition. Unum, on the other hand, argues that
it made a reasonable assessment under the language of the
policies that it was possible for Ms. Lyman to file on time
and that she did not. For the reasons herein, the court rules
that Unum did not abuse its discretion in denying Ms.
Lyman’s claims. Unum appropriately interpreted its own
policies, made a reasoned decision based on sufficient
evidence, and was not required to show prejudice. Thus, Ms.
Lyman’s Motion for Judgment on the Record (Docket No.
47) is DENIED and Unum’s Motion for Summary Judgment
(Docket No. 44) is ALLOWED.
STATEMENT OF FACTS
Lyman was a teacher in the Revere Public Schools and resigned
from that position on June 24, 2014. (See PF ¶
11). Ms. Lyman, through the Revere Public Schools, had
disability insurance coverage governed by a plan (the
“Plan”) issued by Unum to the Massachusetts
Teachers Association (“MTA”). (PF ¶ 2; DF
¶¶ 1-2). The Plan provides two policies under which
Ms. Lyman was covered: the first provides short-term
disability (“STD”) benefits and the second
provides long-term disability (“LTD”)
benefits. (DF ¶ 1; PF ¶ 4). The policies
are governed by the Employee Retirement Income Security Act
of 1974 (“ERISA”). (AR III: CL-STD-922; AR I:
Plan includes a provision, applicable to both the STD and LTD
policies, which provides deadlines for the filing of claims
(“the Provision”). The Provision reads as
you notify Unum of a Claim?:
We encourage you to notify us of your claim as soon as
possible, so that a claim decision can be made in a timely
manner. Written notice of a claim should be sent within 30
days after the date your disability begins. However, you must
send Unum written proof of your claim no later than 90 days
after your elimination period. 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.
(PF ¶ 8; DF ¶ 3; AR III: CL-STD-927). The
elimination period for an STD claim is 30 days and for an LTD
claim is 180 days. (DF ¶¶ 4-5; PF ¶¶
Lyman claims she has been disabled since the last day of her
job, June 24, 2014. (DF ¶ 6; PR ¶ 6). Calculating
from that date of disability, the parties agree that the
applicable timetables for filing an STD and LTD claim under
the Plan are as follows. Ms. Lyman’s claim for STD
benefits was due by October 23, 2014 (90 days after the end
of the 30 day STD elimination period), unless it was not
possible for her to do so or unless she lacked legal
capacity. The proof of loss for the LTD claim was due by
March 22, 2015 (90 days after the end of the 180 day LTD
elimination period), unless it was not possible for her to do
so or unless she lacked legal capacity. As addressed in
detail below, Ms. Lyman filed for STD and LTD benefits, at
the earliest, in June of 2015. (DF ¶ 7; PF ¶ 13; AR
II: CL-STD-17-19; AR VI: CL-LTD-1015).
parties’ principle disagreement, and the question for
the court on summary judgment, is whether Unum abused its
discretion in denying Ms. Lyman an extra year to file her
claims under the “possibility” language of the
Provision. If it was possible for Ms. Lyman to file her claim
in the allotted amount of time, her claims were late. If it
was not possible for her to do so, she is afforded an extra
year under the language in the Provision and her claims were
the plain language of the STD and LTD plans grant Unum
discretion in interpreting the language in its policies. The
Plan provides that “[w]hen making a benefit
determination under the policy, Unum has discretionary
authority to determine your eligibility for benefits and to
interpret the terms and provisions of the policy.” (AR
II: CL-STD-167). The Plan further elaborates:
The Plan, acting through the Plan Administrator, delegates to
Unum and its affiliate Unum Group discretionary authority to
make benefit determinations under the Plan. Unum and Unum
Group may act directly or through their employees and agents
or further delegate their authority through contracts,
letters or other documentation or procedures to other
affiliates, persons or entities. Benefit determinations
include determining eligibility for benefits and the amount
of any benefits, resolving factual disputes, and interpreting
and enforcing the provisions of the Plan. All benefit
determinations must be reasonable and based on the terms of
the Plan and the facts and circumstances of each claim.
(AR II: CL-STD-199-200). As discussed herein, this language
gives Unum discretion to interpret language in the Plan,
including the Provision and its “possibility”
Potential Misrepresentations by Unum
Lyman claims that one of the reasons why it was impossible to
file her claim on time was because Unum misrepresented to her
over the phone that she was not eligible for benefits. Ms.
Lyman claims, through affidavits submitted in both this case
and in her administrative appeal, that in March of 2015, she,
along with her best friend, Vincent Giordano, contacted Unum
and the MTA to discuss her disability and desire to file
claims for STD and LTD benefits under the Plan. (PF ¶
19; AR III: CL-STD-820; Lyman Affidavit ¶¶ 15-16).
Unum disputes this fact. (DR ¶ 19 (“. . . as set
forth in the Affidavit of Deborah Teter, there were no
communications with Ms. Lyman or a representative of Ms.
Lyman prior to June 2015”)). Ms. Lyman claims, and Unum
disputes, that during this conversation Unum informed her
that “she was not eligible for coverage . . . .”
(PF ¶¶ 19, 23; DR ¶ 19). Further, Ms. Lyman
claims that Unum “refused to provide her with the
requisite documentation to apply for benefits,”
although she admits that she received the forms from MTA. (PF
¶¶ 23-24). As detailed below, these disagreements
do not rise to the level of disputed material facts, and do
not preclude the resolution of this case by way of summary
Ms. Lyman’s Application for STD
16, 2015, Unum received an Attending Physician Statement
regarding Ms. Lyman’s STD claim. (DF ¶ 7; PF
¶ 13; AR II: CL-STD-17-19). Therein, Dr. Witts
represented that Ms. Lyman has a diagnosis of “chronic
headache” and also suffers from difficulties with
“sleep/ memory/ concentration/ reading/
writing[.]” (AR II: CL-STD-17). Ms. Lyman posits that
her STD claim was filed in June 2015. (PF ¶ 25
(“Finally, in June 2015, Ms. Lyman filed a claim for
STD benefits with Unum.”)). While this Court will accept
June 2015 as the filing date for STD benefits, the record is
not that clear. For example, it was not until July 15, 2015
that Unum received Ms. Lyman’s Individual Statement
dated July 14, 2015. (DF ¶ 8; PF ¶ 16; AR II:
STD-25-28). On July 24, 2015, Dr. Witts submitted a second
Attending Physician Statement, this time diagnosing Ms. Lyman
with orthostatic hypertension, HTN, cervical disc disease and
chronic headaches. (PF ¶ 14; AR II: CL-STD-116-17). On
August 6, 2015, another doctor, Dr. Hammer, submitted a
letter regarding Ms. Lyman’s psychiatric state, writing
that “[i]n [her] opinion, Ms. Lyman has been
psychiatrically and medically disabled since late 2013/early
2014.” (PF ¶ 17; AR II: CL-STD-100). On August 14,
2015, Unum received the Employer’s Statement for Ms.
Lyman’s claim. (DF ¶ 9; PR ¶ 9; AR II:
CL-STD-77-79). On August 29, 2015, Ms. Lyman’s doctor
submitted additional medical records. (PF ¶ 14; AR II:
October 1, 2015, Unum denied Ms. Lyman’s STD claim. (DF
¶ 12; PF ¶ 31; AR II: 150-52). Unum denied the
claim on the grounds that Ms. Lyman was not covered under the
STD policy as of the date of her disability. (Id.).
Unum stated in relevant part:
We understand you resigned from your employment as of June
24, 2014. Your employer confirmed you did not request, nor
are you currently on an approved leave of absence. In order
for your disability coverage to continue, you would have to
have been on an approved leave of absence through your
employer. Since you have not been on an approved leave of
absence, your disability coverage ended as of June 24, 2014,
the day you resigned, and we are unable to support your
request for disability benefits.
(AR II: STD-150-52).
Ms. Lyman’s Application for LTD
February 9, 2016, Ms. Lyman’s attorney requested an
application for LTD benefits. (DF ¶ 10; PF ¶ 32; AR
II: STD-231). The next day, on February 10, 2016, Unum opened
a claim profile under the LTD policy for Ms. Lyman. (DF
¶ 11; PF ¶ 33; AR IV: CL-LTD-04-06). Ms. Lyman posits
that this is when she filed her LTD claim. (Lyman Memo in
Support (Docket No. 48) at 3). On June 14, 2016, Unum denied
Ms. Lyman’s claim for LTD benefits. (PF ¶ 42; DF
¶ 13; AR V: CL-LTD-987-91). As described below, while
Unum has consistently taken the position that Ms.
Lyman’s application for LTD benefits was untimely, it
has offered various dates for when the application was made,
including June 16, 2015, June 20, 2015 and March 23, 2016,
and when the application was due, including February 27,
2016, February 27, 2015 and March 21, 2015. As noted above,
without the possibility extension, this court calculates that
Ms. Lyman’s LTD benefits application was due by March
June 14, 2016 denial letter, Unum represented that its
decision to deny LTD benefits was because “[t]he policy
allows a certain period of time in which the claim must be
received. We received the claim on March 23, 2016, which was
not within the required time frame.” (AR V:
CL-LTD-988). Under a subheading titled “[I]nformation
That Supports Our Decision,” Unum provided the
The information in the claim file indicates Nancy Lyman
initially stopped working on June 02, 2014 due to your
diagnosis of depression, social phobia, headaches, insomnia
and chronic pain. We received her completed claim on March
In our telephone call on April 27, 2016, Ms. Lyman indicated
that she had not filed a claim because she was not
anticipating being out of work for this length of time.
We received her completed claim on March 23, 2016. According
to the Notice of Proof of Loss provisions in the
policy (outlined below), her claim should have been received
no later than February 27, 2016. Because we did not receive
Ms. Lyman’s claim by this date, we are unable to give
consideration to her claim and benefits will not be payable.
Her claim has been closed.
revised the letter denying Ms. Lyman LTD benefits twice. (PF
¶ 43). On June 23, 2016, Unum sent a letter to Ms.
Lyman’s attorney noting several changes to the
decision, including the following:
• Unum had received Ms. Lyman’s completed claim on
June 20, 2015 and not on March 23, 2016.
• According to the Provision, Unum stated it should have
received the claim no later than February 27, 2015 as opposed
to February 27, 2016.
(AR VI: CL-LTD-1015). Unum then sent another letter on June
27, 2016 once again correcting the dates included in their
reasoning for the LTD benefits denial. Unum’s corrected
We received her completed claim on June 16, 2015. According
to the Notice and Proof of Loss provisions in your policy
(outlined below) the claim should have been received no later
than March 21, 2015. Because we did not receive your claim by
this date, we are unable to give consideration to the claim
and benefits will not be payable.
(Id. at CL-LTD-1024) (emphasis omitted).
the LTD claim was pending, on March 23, 2016, Ms. Lyman
appealed the STD decision. (DF ¶ 14; PF ¶ 39; AR
II: CL-STD-441-42; AR III: CL-STD-633). In the appeal letter,
Ms. Lyman’s attorney wrote, in part:
Unum terminated Ms. Lyman’s claim on the basis that she
was not insured under the terms of the Plan when she ceased
work. This is incorrect, and is directly contradicted by the
information contained in Unum’s file, including without
limitation, confirmation from Ms. Lyman’s employer as
to her date of disability and her last date worked.
(AR II: CL-STD-441).
letter dated June 27, 2016, the same day Unum sent the second
amended denial letter for Ms. Lyman’s LTD claim, Unum
rendered a decision on Ms. Lyman’s appeal of STD
benefits. (AR III: CL-STD-753-58). Unum informed Ms.
Lyman’s attorney that the STD claim had been
incorrectly denied for lack of coverage, but it was still
denied because, like Ms. Lyman’s LTD claim, it was not
filed on time. (DF ¶ 15; PR ¶ 15; AR III:
CL-STD-754). Unum provided that:
It was determined that your client did not submit her claim
within the required timeframes as specified by the policy.
Because a new basis for denial is being cited, you and your
client will be provided new appeal rights.
... your client’s claim was initially denied by the
Benefits Center citing her coverage ended on June 24, 2014.
The appeal review did not address the coverage issue or if
your client satisfied the definition of disability. During
the appeal review, Unum recognized that your client’s
claim was submitted late. Outlined below are Unum’s
findings as it relates to the late filing.
The Short Term Disability file reflects an Attending
Physician’s Statement was received on June 16, 2015.
On July 15, 2015, your client submitted an Employee
Statement, completed by her on July 14, 2015. She provided a