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To reverse an ERISA Administrator decision, it must be proven arbitrary and capricious



After Amy Wright quit her job in 2017, she made two claims with her insurance company for benefits that would accrue to her only if she could prove she was disabled. Wright provided a wide range of medical evidence with mixed indicators of disability. The treating doctor did not agree if she was disabled. In the end, her planning administrator denied both allegations because she found that her evidence was insufficient to establish disability. IA Mitt Wright v. Reliance Standard Life Insurance Company, a Foreign Company, No. 19-14643, United States Court of Appeal for the Eleventh Circuit (January 29, 2021), the Court was asked to rule only if the ERISA Administrator's decision was Arbitrary & Capricious.

Amy Wright served as Vice President of Health Information Services at Integrity Health Care. Wright's job involved light physical exertion. Integrity provided Wright with two insurances through Reliance Standard Life Insurance: (1) long-term disability insurance and (2) life insurance. Both plans were always subject to the requirements of the Employment Retirement Income Security Act of 1974 (ERISA).

Reliance's long-term disability guaranteed payments to Wright if she could not "perform the essential and material tasks [her job]" for 90 consecutive days due to injury or illness. Reliance's life insurance policy waived Wright's premium commitments for one year if she "became [ame] completely disabled" for at least six months. The life insurance policy defined "total disability" as "complete inability to perform any form of pay or gainful employment that [she was] suits the education, training or experience." Both guidelines gave Reliance the "discretionary authority to interpret" their terms and "to determine eligibility for benefits."

On August 7, 2017, Wright stopped working. She raised claims for benefits under the long-term disability policy and for waiving premiums under the life insurance policy. After retiring, Wright sought medical attention several times a month for four months. The medical reports from these months presented a mixed picture of health. On the one hand, Wright complained of pain and fatigue and was diagnosed with a constellation of health problems, including fibromyalgia, dysautonomia, and postural orthostatic tachycardia syndrome. On the other hand, repeated physical examinations found that she showed normal strength, range of motion and neurological and psychological condition.

Trust denied Wright's long-term disability. It explained that the medical evidence was somewhat inconsistent with her diagnoses and in any case did not establish disability. Trust denied Wright's claim to waiver under her life insurance policy. Wright administratively appealed the rejection of both claims.

Dr. Pamela Noel, diagnosed Wright with more than a dozen medical conditions and concluded that Wright was "completely and permanently disabled." Dr. Robert Martinez, acknowledged Wright's widespread concerns and reported symptoms. He performed physical and neurological examinations and found that everything was normal except for some limitations on Wright's range of motion and an unsteady gait. He said she was capable of "full-time jobs and activities." Finally, Reliance asked another doctor, Dr. Donald Tan-Fog Lee, to review Wright's medical records. He concluded that Wright could work on a normal schedule, with some accommodating and limiting of her physical exertion.

Wright sued Reliance in federal district court under ERISA. Reliance filed a summary judgment claiming that Wright had failed to prove that she was disabled under either policy and that substantial evidence in the minutes supported the conclusion that her claim was not arbitrary and capricious. The district court handed down the verdict for trust.

ANALYSIS

In the ERISA context, when a policy assigns an administrator with discretion, an appellate court can only hold the applicant if it concludes that the administrator's denial was' arbitrary and capricious. .

First and foremost, Wright argues that Reliance arbitrarily and capriciously denied both of her claims. Wright's first claim – for long-term disability – required her to prove that she was completely disabled during the 90-day "elimination period" from August 7 to November 5, 2017. She was completely disabled if she "[could] did not fulfill the significant and material the data for [her] regular occupation. "

Wright's second claim – concerning the waiver of life insurance premiums – required her to prove it for six months from 7 August 2017 to 7 February 2018, she had “complete inability to engage in any form of work for pay or profit for which [she was] is suitable for education, training or experience. "

The eleventh lane ended that trust did not arbitrarily and capriciously deny any claim. Although Wright's own preferred physicians claimed that she could not work, they repeatedly noted that her gait, range of motion, strength, and many other physical conditions were normal during that period. She complained of a wide range of symptoms and illnesses, but doctors found that she was exercising and seemed to think they could prescribe her even stricter exercise programs. And while some doctors said she was completely disabled, others said – like Dr. Martinez and Dr. Tan-Fog Lee – that she could work.

Although it was undeniably in Reliement's short – term interest to deny Wright's claims that the presence of a structural conflict of interest is a remarkable fact in today's market and a conflict of interest is a common feature of the ERISA plans. Wright failed to demonstrate that the Reliance & # 39 ;s conflict of the mill made its denials arbitrary and capricious.

Reliance denied Wright's claim based on conflicting, reliable evidence, including from Dr. Martinez, who treated her personally and concluded that she was not Disabled.

In the ERISA context, the eleventh district itself had to decide whether the district court's conclusion was supported by the administrative post, regardless of how it got there. The Elventh Circuit found, after reviewing all the evidence presented and the work of the district court, that the district court was correct in concluding that Reliance's denial of Wright's allegations was not arbitrary and capricious.

ERISA allows a lot of discretion. to plan administrators. When, as in Wright's statement, even her preferred doctor who concluded that she was completely disabled repeatedly stated that her gait, range of motion, strength and many other physical conditions were normal and that contradicted their conclusions and gave strength opinions from the administrator's experts. As there were good reasons for the administrators' decision to reject her claim that the decision was neither arbitrary nor capricious, the court's decision was upheld.


© 2021 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to serving as an insurance consultant specializing in insurance coverage, insurance claims handling, fraud and insurance fraud almost equally for insurance companies and insurance companies. He also acts as an arbitrator or mediator for insurance-related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims lawyer and more than 52 years in the insurance industry. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award.

For the past 53 years, Barry Zalma has devoted his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurers and their claims staff to become insurers.

Go to the podcast Zalma On Insurance at https://anchor.fm/barry-zalma; Follow Zalma on Twitter at https://twitter.com/bzalma ; Go to Barry Zalma videos on Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ Read posts from Barry Zalma at https://parler.com/profile/Zalma/ posts; and Read the last two issues of ZIFL here.


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