To Reverse an ERISA Administrator’s Decision it Must be Proved to be Arbitrary & Capricious

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When Experts Provide Reasonable, Professional and Adverse Opinions ERISA Allows for Reasonable Decision

After Amy Wright stopped working in 2017, she made two claims with her insurer for benefits that would accrue to her only if she could prove that she was disabled. Wright provided a wide range of medical evidence with mixed indicators of disability. Treating physicians disagreed as to whether she was disabled. Ultimately, her plan administrator denied both claims because it determined that her evidence was insufficient to establish disability. In Amy Wright v. Reliance Standard Life Insurance Company, a Foreign Corporation, No. 19-14643, United States Court Of Appeals For The Eleventh Circuit (January 29, 2021) the court was called upon to decide only if the decision of the ERISA administrator was Arbitrary & Capricious.

FACTS

Amy Wright worked as the vice president of health information services at Integrity Health Care. Wright’s job entailed light physical exertion. Integrity provided Wright with two policies through Reliance Standard Life Insurance: (1) long-term disability insurance, and (2) life insurance. Both plans were at all times subject to the requirements of the Employment Retirement Income Security Act of 1974 (ERISA).

The Reliance long-term disability policy guaranteed payments to Wright if, due to injury or sickness, she couldn’t “perform the substantial and material duties of [her job]” for 90 consecutive days. The Reliance life-insurance policy waived Wright’s premium obligations for a year if she “bec[ame] totally disabled” for at least six months. The life-insurance policy defined “total disability” as the “complete inability to engage in any type of work for wage or profit for which [she was] suited by education, training, or experience.” Both policies gave Reliance the “discretionary authority to interpret” their terms and “to determine eligibility for benefits.”

On August 7, 2017, Wright stopped working. She brought claims for benefits under the long-term disability policy and for a waiver of premiums under the life-insurance policy. After she stopped working, Wright sought medical care multiple times per month for four months. The medical reports arising from those 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 exams found her to exhibit normal strength, range of motion, and neurological and psychological condition.

Reliance denied Wright’s long-term disability claim. It explained that the medical evidence was somewhat inconsistent with her proffered diagnoses and in any event didn’t establish disability. Reliance denied Wright’s waiver-of-premium claim under her life-insurance policy. Wright administratively appealed both claim denials.

Dr. Pamela Noel, diagnosed Wright with more than a dozen medical ailments and concluded that Wright was “totally and permanently disabled.” Dr. Robert Martinez, acknowledged Wright’s wide-ranging concerns and reported symptoms. He administered physical and neurological exams and found everything to be normal except some limitations to Wright’s range of motion and an unsteady gait. He opined that she was capable of “full-time work duties and activities.” Finally, Reliance asked another doctor, Dr. Donald Tan-Fog Lee, to review Wright’s medical records. He concluded that, with some accommodations and limitations on her physical exertion, Wright could work a normal schedule.

Wright sued Reliance in federal district court under ERISA. Reliance filed a motion for summary judgment arguing that Wright had failed to prove she was disabled under either policy and that substantial evidence in the record supported the conclusion that its claim denials weren’t arbitrary and capricious. The district court entered judgment for Reliance.

ANALYSIS

In the ERISA context, when a policy vests an administrator with discretion, an appellate court may hold for the claimant only if it concludes that the administrator’s denial was “arbitrary and capricious.”

First and centrally, Wright argues that Reliance arbitrarily and capriciously denied both her claims. Wright’s first claim—for long-term disability—required her to prove that, for the 90-day “elimination period” from August 7 through November 5, 2017, she was totally disabled. She was totally disabled if she “[could] not perform the substantial and material duties of [her] regular occupation.”

Wright’s second claim—for a waiver of life-insurance premiums—required her to prove that, for six months from August 7, 2017 to February 7, 2018, she had the “complete inability to engage in any type of work for wage or profit for which [she was] suited by education, training, or experience.”

The Eleventh Circuit concluded that Reliance did not arbitrarily and capriciously deny either claim. Although Wright’s own preferred doctors asserted that she was unable to 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 ailments, but doctors noted that she was exercising and seemed to think they could prescribe her even more rigorous exercise programs. And while some doctors said that she was totally disabled, others—like Dr. Martinez and Dr. Tan-Fog Lee —said she was able to work.

Although it was undeniably in Reliance’s short-term interest to deny Wright’s claims the presence of a structural conflict of interest is an unremarkable fact in today’s marketplace and a conflict of interest is a common feature of ERISA plans. Wright failed to demonstrate that Reliance’s run-of-the-mill conflict rendered its denials arbitrary and capricious.

Reliance denied Wright’s claim based on conflicting, reliable evidence, including from Dr. Martinez, who treated her in person and concluded she wasn’t disabled.

In the ERISA context, the Eleventh Circuit needed to determine for itself whether the district court’s conclusion was supported by the administrative record regardless of how it arrived there. The Elventh Circuit, after reviewing all the evidence presented and the work of the District Court, found that the district court was correct to conclude that Reliance’s denials of Wright’s claims weren’t arbitrary and capricious.

ZALMA OPINION

ERISA allows a great deal of discretion to plan administrators. When, as in Wright’s claim,  even her preferred doctors who concluded she was totally disabled repeatedly noted that her gait, range of motion, strength, and many other physical conditions were normal and which contradicted their conclusions and gave strength to the opinions of the administrator’s experts. Since there were good reasons for the administrators decision to reject her claim that decision was neither arbitrary or capricious so the trial court’s decision was affirmed.


© 2021 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves 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 handling lawyer and more than 52 years in the insurance business. 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.

Over the last 53 years Barry Zalma has dedicated 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 make it possible for insurers and their claims staff to become insurance claims professionals.

Go to the podcast Zalma On Insurance at https://anchor.fm/barry-zalma;  Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at 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 last two issues of ZIFL here.

 

 

 

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