Evans v. UNUMProvident Corp.

This ERISA case, decided in 2005 , is another case examining the “arbitrary and capricious” standard that the Court must use in reviewing most of these cases from the lower Court.

In this case, the Plaintiff/Insured worked as a nursing home administrator. She began to suffer from complex intractable seizures. Plaintiff applied for long term disability benefits under ERISA, which were initially granted and then terminated by the Defendant. The Plaintiff filed suit seeking damages resulting from this termination and for reinstatement of her long term disability benefits. The district court granted judgement in favor of the Plaintiff, and the Defendant appealed.

The lower court held that the Defendant had acted arbitrarily and capriciously in terminating the Plaintiff’s long term disability benefits because the Defendant failed to provide a reasoned explanation, based on both the record in the case and express language of the long term disability policy, for terminating the long term disability benefits. The Court found that the Defendant’s decision to rely solely on file reviews by its in-house physicians was questionable in light of the critical credibility determinations made in those file reviews, the factual inaccuracies contained therein regarding the Plaintiff’s treatment history, and the fact that the file reviews categorically dismissed the reliable opinion of the Plaintiff’s treating physician that the stress factor militated against the Plaintiff’s return to work at her administrative position. The lower court was affirmed.

As in the previous cases we have blogged about, the “arbitrary and capricious” standard is difficult to overcome but not impossible. An insurer must act in a measured and reasoned way, and set forth independent reasons for the long term disability benefit termination, or it may not withstand scrutiny by the courts.

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.