Attorneys who do not handle ERISA claims often times make the mistake that there is not much difference between an ERISA insurance claim and a regular insurance claim. This is a mistake. The United States Court of Appeals for the Fifth Circuit issued an opinion on April 18, 2014, that discusses how courts looks at ERISA claims. The case is styled Cynthia Spenrath v. The Guardian Life Insurance Company of America. Here is some of the relevant information related to the case. However, for anybody dealing with an ERISA case, it is necessary to read the entire case and other cases dealing with ERISA law and issues.
Spenrath worked at Protect Controls, Inc. as an order entry manager. In 2005, Spenrath started having seizure-like episodes in which she would be non-responsive for about five minutes. She asserted that the episodes were accompanied by swishing in her ears, limb weakness, and an inability to move or speak. Spenrath’s primary care physician, Dr. Michael DiTeresa, referred her to two neurologists, Dr. Balbir Singh and Dr. J. William Lindsey. Neither neurologist made a definitive diagnosis, but they mentioned the possibility of multiple sclerosis based on abnormal MRI results and recommended additional testing. Spenrath did not undergo additional testing. Though she continued to take anticonvulsant medication, Spenrath did not visit the neurologists after 2005. In 2008, Spenrath experienced difficulty doing her job, with a diminished ability to focus and type information into the computer. When she failed to complete several assignments, she was given a negative performance review and a salary reduction. Shortly after the negative review, she ceased working on February 22, 2008. On May 7, Spenrath submitted a claim for long-term disability benefits under the company’s ERISA Plan, and claimed commencement of disability as of February 22, 2008.
The Plan’s administrator, Guardian Life Insurance Company (“Guardian”) began a review of the long-term disability claim. Under the Plan, Guardian has “discretionary authority to determine eligibility for benefits and to construe the terms of the [Plan] with respect to claims.” In order to receive long-term disability payments, the plan sets forth several requirements:
(a) You must (i) become disabled while insured by this plan; and (ii) remain disabled for this plan’s [ninety-day] elimination period.
(b) You must be: (i) under a doctor’s regular care for the cause of your disability, starting from the date you were first disabled; and (ii) receiving medical care appropriate to the cause of your disability and any other sickness or injury which exists during your disability.
(c) You must send us written documentation of: (i) medical evidence in support of the limits causing your disability . . . .
The Plan defines “disability or disabled” as “physical, mental or emotional limits caused by a current sickness or injury” that preclude the full time performance of the major duties of the claimant’s occupation. The ninety-day elimination period is the length of time a claimant must be disabled prior to becoming eligible for long-term disability.
Here is some law cited by the Court in it’s decision to uphold the denial of benefits to Spenrath:
We review a district court’s grant of summary judgment de novo in the ERISA context, applying the same standard as the district court.
Where the benefits plan “gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan” we review only for an abuse of discretion.
The plan administrator’s factual determinations are also reviewed for abuse of discretion.
The plaintiff carries the burden of proving abuse of discretion on the part of the plan administrator.
Under this standard, “[i]f the plan fiduciary’s decision is supported by substantial evidence and is not arbitrary and capricious, it must prevail.”
“Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
“A decision is arbitrary if it is made without a rational connection between the known facts and decision.”
“Ultimately, [this court’s] review of the administrator’s decision need not be particularly complex or technical; it need only assure that the administrator’s decision fall[s] somewhere on a continuum of reasonableness–even if on the low end.”
As can be seen from the above quotes from the opinion, these cases are tough and both a claimant and the claimants’ attorney need to understand this.
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