A recent case from the federal district court of Minnesota, Payzant v. UNUM Life Ins. Co. of America, 402 F.Supp.2d 1053 (D. Minn. 2005), features an issue that comes up occasionally in ERISA disability cases. In Payzant the plaintiff suffered from fibromyalgia, a debilitating disease that is notoriously difficult to diagnose and treat. UNUM denied her claim, in large part because it claimed Payzant had not submitted objective medical evidence of the disease. In court Payzant argued that the language of the disability policy didn’t require this type of proof and that, even if it did, she had presented objective medical evidence. The court agreed with Payzant on both counts.
In light of the absence of policy language requiring objective evidence and the fact that the diagnosis of fibromyalgia is primarily based on subjective reporting of symptoms, the judge held that UNUM's requirement of objective evidence was a "procedural irregularity." The court also ruled that UNUM's actions constituted a "serious breach of fiduciary duty" that justified reversing its denial of Payzant's claim. For good measure, the court also determined that even if objective evidence were required by the policy language, Payzant’s physicians had supplied that type of evidence in their medical records.
Insurers who try to rely on extra-contractual requirements or limitations to coverage are on thin ice.