The Court of Appeals for the Seventh Circuit held that the claims administrator of a long-term disability plan was not entitled to rely upon a limitation set forth in the plan document, but not mentioned in the summary plan description given to participants, for the purpose of denying a claim for benefits. The plan document included a provision for a 24-month cap on benefits for those disabled due to sickness or with injuries primarily based upon self-reported symptoms, along with those disabled due to mental illness, alcoholism, or drug abuse. While the summary plan description noted the limitation on disabilities due to mental illness, alcoholism, or drugs several times, it made no mention of the limitation for disabilities based upon self-reported symptoms. Invoking the limitation for self-reported symptoms under the plan document, the claims administrator informed the participant that she would no longer receive benefits after 24 months. The participant brought suit challenging the denial of benefits.
The Seventh Circuit ruled in favor of the participant, explaining that while a summary plan description need not identify every possible contingency affecting a participant’s eligibility for benefits, the self-reporting symptoms limitation was not an “idiosyncratic contingency” concerning only a few people, but a broad limitation on eligibility for benefits. As a result, the participant’s benefits were reinstated, but the administrator was permitted to review her eligibility under the plan prospectively. Exactly when a limitation represents an idiosyncratic contingency or a broad limitation was not clearly answered by the Seventh Circuit. (Weitzenkamp v. Unum Life Ins. Co. of America, 7th Cir. 2011)