This ERISA case, decided in 2015, is another case dealing with the “arbitrary and capricious”
standard. However, the case also has some interesting information about conflicts of interest in these types of cases.
The Plaintiff/Insured filed was an employee of the Defendant and filed for disability because of back problems. The Plaintiff’s long term disability benefits under ERISA, However, she was later notified that she would no longer be receiving these long term disability benefits because the Administrator had determined that the medical evidence no longer supported a finding of disability. The Plaintiff appealed the decision, and the denial affirmed. The Plaintiff claimed that the doctor who’s opinion the Administrator based the decision upon lied about speaking to her treating physicians, and submitted affidavits from her doctors saying that they had not spoken with the Defendant’s doctor. The Administrator declined to add these documents to the record on the basis that they were cumulative or not available at the time the Plaintiff exhausted her administrative remedies. The Plaintiff then filed suit in the district court, which granted summary judgment in favor of the Defendant. On appeal, the Plaintiff argues that the Defendant Administrator had a conflict of interest because the Defendant both funded the disability program and made benefits eligibility decisions. The Court held that the conflict did not exist because the structure of the Defendant meant that the benefits were paid into a trust which was administered by a separate board of directors. The Defendant next argues that she should have been allowed to supplement the record with the affidavits of her doctors. The Court finds that the Administrator did give the Plaintiff time to supplement the record before the decision was made, but the Plaintiff did not supplement with the affidavits until over a year after the decision was made, so the administrator did not have ample opportunity to examine and consider these records in rendering its decision, so this argument failed. Finally, the Plaintiff argues that the Administrator’s decision in denying her long term disability benefits was arbitrary and capricious, but the Court disagreed. The Court points out that the Administrator did consider the records available at the time it made its decision, and based the decision on these records, so the decision was not arbitrary and capricious.
This case is another example of the necessity of making the record in order to prevail in your case. Here, for some reason, when the Plaintiff saw what she believed to be lie from the Defendant’s physician, she waited a whole year to obtain the affidavits which may have demonstrated this. The Court found that this was too late. If the Plaintiff had timely submitted these affidavits, she might have prevailed in this case.
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.