Dallas and Fort Worth insurance lawyers need to understand how ERISA policies are different from other types of policies. The difference is that a “plan administrator” makes a decision on a claim and if the claimant disputes that decision and files a lawsuit, the Courts look at the decision and decide whether or not the plan administrator abused their discretion in arriving at their decision.
A decision from the United States 5th Circuit is a good case to read to understand how the courts look at ERISA claims. The style of the case is Patrizia Lalonde v. Christus Health. Here is what we learn.
The facts can be learned by reading the case.
The analysis was as follows.
We review de novo the district court’s conclusion that an ERISA plan administrator did not abuse its discretion in denying disability benefits. Under this approach, we review the plan administrator’s decision from the same perspective and with the same standard of review as the district court. When a benefits plan’s terms grant the plan administrator discretionary authority to determine eligibility for benefits or construe the terms of the plan, which it does here, we review the determination to deny benefits for abuse of discretion. We will affirm a plan administrator’s determination to deny benefits if it is “supported by substantial evidence and is not arbitrary or capricious.” “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.'”. “The fact that the evidence is disputable will not invalidate the decision; the evidence need only assure that the administrator’s decision falls somewhere on the continuum of reasonableness–even if on the low end.”
Lalonde claims that the Plan abused its discretion in denying her WRB based on her at-work injury. Specifically, she asserts that the Plan “ignored its obligations” by refusing to send Lalonde to Approved Physicians. Thus, Lalonde concludes that the Plan’s decision is not supported by substantial evidence because it “prevented any evidence from coming into existence by refusing to send Lalonde to a Plan Approved Physician.” In support of her claim that the Plan prevented her from generating a complete record, Lalonde points to the Plan’s denial of Dr. Gabbie’s neurosurgeon referral and recommendation for steroid injections. She also claims that she attempted to return to Dr. Gabbie in August 2010, but the Plan ignored her request. Lalonde concedes that no Approved Physicians concluded that she was temporarily totally disabled, but she contends that the lack of evidence on this point is the direct result of the Plan’s behavior. Additionally, Lalonde argues that the Plan relied on reports from doctors who had not physically examined her, rendering its decision arbitrary and capricious. Despite Lalonde’s claims that the Plan denied her access to doctors,
inhibiting the development of a complete and accurate record, she offers no legal support for the proposition that the Plan has an obligation to send her to multiple doctors for this purpose. Additionally, the record does not support her claim that she was prevented from seeing Approved Physicians. First, Lalonde received immediate medical care from Dr. Gabbie following her injury, and she returned for two additional follow-up visits and underwent an MRI. For more than a year, the Plan continued to send her to additional physicians and for diagnostic testing. Although the Plan’s responses to her requests were less than prompt, the Plan did not prevent her from developing the medical record with evidence of her condition. There are multiple evaluations from physicians in the record as well diagnostic reports.
Second, the Plan provided specific reasons for its refusal to send Lalonde to the neurosurgeon suggested by Dr. Gabbie and its denial of coverage for the cortisone injections. In a letter dated August 12, 2010, the Plan explained that, based on Dr. Ford’s review of Lalonde’s medical records, neither the neurosurgeon consultative examination nor the injections were medically necessary. The Plan’s decision was not a blanket denial with no support; it was based on the opinion of a medical professional.
Third, Lalonde refused two opportunities to further develop the medical record. She refused to undergo the CT myelogram, which would have assisted the Plan in determining whether her herniated discs were related to her degenerative condition or whether they were the result of her at-work injury. She also refused to attend the IME scheduled by the Appeals Committee, which is what prompted the Plan to send her file to Dr. Brooks for a peer review. Lalonde cannot claim that the Plan was thwarting her attempts to develop the record, but then refuse to participate in the record’s development.
Having concluded that the Plan did not prevent Lalonde from attaining medical evaluations and developing the record as to the extent of her medical impairments, we turn to Lalonde’s main claim–that the Plan’s decision was not supported by substantial evidence. We agree with the district court that there is sufficient evidence in the record to support the Plan’s determination that Lalonde was not temporarily totally disabled and, therefore, ineligible for benefits. Dr. Brooks reviewed the medical record, including the notes from physicians who treated Lalonde, their evaluations, and reports from diagnostic tests, and Dr. Brooks concluded that Lalonde had at most a soft tissue strain. Dr. Brooks’s opinion is also consistent with other evidence in the record, including the evaluations by Drs. Weiner, Ford, and Blair, and the two MRIs, which indicated that Lalonde’s back problems were degenerative in nature. While only Dr. Weiner physically evaluated Lalonde, ERISA plan administrators may rely on a wide variety of medical evidence in making a decision, including evaluations from physicians who did not evaluate the claimant in person. Collectively, this constitutes substantial evidence.
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