In this ERISA case, decided in 2006, the question before the Court is whether a long term disability plan administrator acted arbitrarily and capriciously in denying the claimant/Plaintiff’s long term disability benefits under ERISA.
This case is another examining the employer’s duty to not be “arbitrary and capricious” in it’s determination of whether or not a Plaintiff is entitled to long term disability benefits under ERISA. In this case, the Plaintiff had been severely injured in car accident and she began experiencing renewed pain. Her doctors could not explain why her pain had reemerged. She applied for long term disability benefits, which was denied by the administrator of her plan. The Plaintiff appealed the denial and the administrator hired a physician to review the file. This physician, after only a file review, concluded that the Plaintiff’s condition had improved and that she was capable of performing sedentary work. Based on this, the administrator continued to deny benefits. The Plaintiff took the matter to the district court in Kentucky, who found in favor of the administrator. However, the Court of Appeals found that the administrator had not relied upon an application of the relevant evidence to the occupational standard. The Court found that the administrator’s physician had not given reasons for his conclusions, never discussed the employee’s job duties, and had evaluated the Plaintiff’s ability to do sedentary work even though the term “sedentary work” did not appear in the plan’s terms. In the addition, the Court found that the administrator had given greater weight to its physician than to the employee’s treating doctor, even though the physician only performed a file review and never saw the Plaintiff. Therefore, the Court of Appeals reversed the lower court and remanded the case back to them with instructions or remand back to the administrator for a determination of whether or not, under these findings, the Plaintiff was entitled to benefits under the plan.
Once again, in ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions. This case demonstrates that the arbitrary and capricious standard can be overcome if the administrator does not ground its decisions in facts and evidence.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.