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A new federal appeals court ruling could help employers' disability plan administrators review long COVID claims in a way that will hold up against litigation.
A three-judge panel at the 6th U.S. Circuit Court of Appeals ruled in favor of a disability plan administrator Thursday, and against a worker with long COVID, in a case involving questions about whether the administrator had used a reasonable claim review process.
Related: Long COVID's impact on the workforce: A Q&A with Bishoy Rizkalla
The district court in the case, Brandi Goodwin v. Unum Life Insurance Company of America, sided with Unum Life, a subsidiary of Unum.
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A lawyer for Goodwin declined to comment on the case.
Unum said it does not comment on the specifics of a particular customer's claim.
ERISA: The Employee Retirement Income Security Act calls for the federal courts to give benefit claim administrators broad discretion over administering claims and to overturn the administrators' decisions only when the the administrators' decisions are arbitrary.
The case: Goodwin, a part-time nursing assistant at a hospital in Ohio, contracted COVID. Her job required her to be able to life 100 pounds and to stand or walk from eight to 12 hours per day.
Unum Life paid a claim for her for short-term disability benefits but later rejected her claim for long-term disability benefits.
She filed a suit in August 2022.
The opinion: In the 6th Circuit opinion, Judge Amul Thakur looks at some of the reasons he found Unum Life's decision to be reasonable.
Goodwin's doctors produced cardiac stress test results, exercise stress test results and other reports that showed Goodwin would have trouble working. Unum's doctors found that the test results did not show Goodwin was incapable of working. "Because Unum did not cherry-pick or disregard evidence, this factor doesn't cut against Unum," Thakur writes.
Similarly, Unum's file reviewers disagreed with Goodwin's providers about whether she could work, but one of her nurse practitioners said she could return to work.
"Therefore, Goodwin's treatming medical professionals weren't uniformly of the opinion that she could return to work," Thakur says. "So, this factor doesn't cut against Unum."
Simply preferring the opinion of one physician over another is not arbitrary or capricious, Thakur adds.
Thakur acknowledges that Unum had a potential conflict of interest, because it was both the insurer of the disability plan and the administrator, but he says Goodwin would have to provide concrete evidence that the conflict materially affected Unum's decision.
"Good win points to no such record evidence," Goodwin writes. "Therefore, though relevant, Unum's conflict doesn't weigh heavily in our analysis."
Goodwin's file also includes many normal test results and normal performance on physical examinations, and that also supports Unum's decision, Goodwin says.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
