Under De Novo Review, Insurer May Rely on “Regular Care” Requirement Even If Not Expressly Articulated as a Standalone Basis for Denial

In Jones v. Unum Life Insurance Company of America, No. 24 C 3911, 2026 WL 96985 (N.D. Ill. Jan. 13, 2026), the Northern District of Illinois held that, where de novo review applies, an insurer may rely on a plan’s “regular care of a physician” requirement in litigation even if that provision was not expressly framed as an independent ground for denial during the administrative process. The court emphasized that de novo review requires an independent determination of benefit entitlement based on the plan terms and the full record, rendering alleged procedural deficiencies in the claims process largely irrelevant.

The claimant, a Whole Foods employee, received short-term disability benefits followed by approximately two weeks of long-term disability (“LTD”) benefits before Unum terminated the claim effective June 8, 2023. The claimant sued under ERISA § 502(a)(1)(B), arguing that Unum improperly terminated benefits and could not rely on the plan’s “regular care” requirement because it did not clearly identify that requirement as a basis for denial during administrative review.

The court rejected that argument at the outset. Although ERISA and its implementing regulations require administrators to provide claimants with the “specific reasons” for an adverse determination, the court explained that those requirements do not constrain the court’s analysis when review is de novo. Citing Marantz v. Permanente Medical Group and Dorris v. Unum Life Insurance Co. of America, the court reiterated that de novo review in the ERISA context is not a review of the administrator’s reasoning at all, but rather an independent judicial determination of whether the claimant satisfies the plan’s contractual requirements.

The court distinguished Seventh Circuit authority prohibiting “post hoc rationales,” including Halpin v. W.W. Grainger, Inc., explaining that those cases arose under the arbitrary-and-capricious standard, where courts defer to the administrator’s reasoning and therefore cannot uphold a denial based on grounds not invoked during the administrative process. That concern, the court explained, does not exist under de novo review, where the court owes no deference to the administrator and is tasked with applying the plan terms itself.

Importantly, the court also rejected the claimant’s assertion that Unum had violated ERISA’s notice requirements in the first place. While Unum did not label “failure to remain under regular care” as a standalone ground for denial, both the initial termination letter and the appeal decision repeatedly cited the claimant’s lack of ongoing treatment, gaps in care, and failure to pursue recommended diagnostic testing. Each letter also expressly stated that Unum relied on the plan’s definition of disability, which included the requirement that the claimant be under the regular care of a physician. Accordingly, this was not a case where the insurer attempted to rely on an entirely new exclusion or limitation raised for the first time in litigation.

The court further rejected the claimant’s argument that he was prejudiced by Unum’s reliance on the regular-care provision. The court emphasized that medical treatment is not a procedural hurdle imposed by insurers to “perfect” a claim, but rather a substantive plan requirement designed to confirm disability, prevent malingering, and minimize loss where treatment may improve functional capacity. The claimant’s contention that he would have pursued more consistent care had the issue been emphasized earlier was insufficient to establish prejudice, particularly given the plan’s clear language placing the burden on the claimant to prove ongoing disability.

The court also addressed—and rejected—the claimant’s argument that his failure to remain under regular medical care should be excused because he could not afford treatment after Unum terminated benefits. Although the claimant told Unum that he could not afford continued physical therapy or MRI imaging, the court held that financial hardship does not excuse compliance with a regular-care requirement under an ERISA-governed plan. The court noted that authority recognizing inability to pay as an excuse largely predates ERISA or arises in non-ERISA contexts, and several courts have questioned whether financial hardship is relevant at all when enforcing plan terms.

Even assuming that financial hardship could excuse noncompliance, the court found that the claimant failed to meet his burden of proof. The record showed that he missed or declined recommended diagnostic testing while still insured and receiving benefits, offered no concrete evidence of his financial condition, and failed to demonstrate that lower-cost or alternative treatment options were unavailable. Under de novo review, the court emphasized, evidentiary gaps cut against the claimant.

Having concluded that Unum was entitled to rely on the regular-care requirement—and that the claimant failed to establish either compliance with that requirement or a valid excuse for noncompliance—the court held that the claimant was not disabled within the meaning of the plan. The court entered judgment for Unum without reaching disputes concerning occupational classification or functional capacity.