Attorneys who handle ERISA claims can tell you how difficult these ERISA cases are to win. When someone makes a claim under an ERISA policy, the plan administrator renders a decision. The claimant is advised how to appeal the decision if the claimant does not like the result. When the claim is denied on appeal, the only thing left to do is to file a lawsuit.
The case is going to be in a Federal Court. The claimant is not entitled to a jury trial. A Federal Judge then reviews the materials / information that was before the plan administrator at the time they made their decision. The standard the Federal Judge uses in reviewing the decision is called an “abuse of discretion” standard. In other words did the plan administrator abuse the discretion given them by the plan when rendering their decision. No new information is allowed to be presented to the Federal Judge. Only the information used when the claim was originally filed and any information added at the time of appeal can be looked at under this abuse of discretion standard.
The other way for the case to proceed is “de novo.” Under the de novo review, a claimant essentially gets a second bite at the apple in retrying the case. In other words the claimant gets to provide new information for the Federal Judge to consider in reaching a decision.
To be able to get a de novo review can make a big difference. The U.S. District Court, Southern District, Houston Division, rendered an opinion in September 2016, that is favorable for helping a claimant get a de novo review on their claim. The case is styled, Wilfred Brasseur v. Life Insurance Company of North America.
This case deals with the discretionary clause in the plan documents a company has for it’s employees. When a plan does not have a discretionary clause, a claimant can be entitled to a de novo review. The opinion is an excellent case for an ERISA attorney to read to find a way to help some of the people who come in who have ERISA claims that have been denied.