In this 2004 ERISA case, the employee claimed to suffer from chronic fatigue syndrome. Neither the initial claim denial nor the subsequent determinations on appeal explained why these findings in her initial statement and her subsequent lengthy and detailed appeal letter were insufficient. Inter alia, the court held that the plan administrator was entitled to evaluate the evidence submitted and find it lacking on any reasonable ground. However, it was not entitled to fail to inform the employee of why the evidence she had submitted was found deficient in the first place. Although the denial letter on which plaintiff’s second appeal was based was far more specific than the first denial letter, it still failed to include the criteria upon which the determination was based and to inform the employee of her rights to access her file. Because the denial notice on the second appeal again failed to provide the required information, the denial of the third appeal also violated ERISA. The administrator’s failure to provide the required information as to the criteria it relied upon and the rights attendant upon the appeal rendered its determination so procedurally flawed as to be arbitrary and capricious.
The ERISA plan’s motion for summary judgment was denied and its determination vacated. The employee’s cross-motion for summary judgment was granted to the extent that the plan administrator’s determination was vacated but was otherwise denied. The case was remanded to the plan administrator for reconsideration. The employee’s request for costs and attorney’s fees was granted.
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.