Here is a rare win in an ERISA case.  Unfortunately the win is the the 7th Circuit Court of Appeals rather than the 5th Circuit which controls most ERISA plans for readers of this blog.

The ERISA case is styled, Susan Hennen v. Metropolitan Life Insurance Company.  The case does illustrate how to win an ERISA case.

Hennen had received short term disability (STD) benefits for two years as the result of a back injury.  Hennen then applied for long term disability (LTD) benefits.  The disability plan that Hennen had contained a two year limit for neuromusculoskeletal disorder, subject to exceptions, including one for radiculopathy, a “Desease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.”  After Metlife terminated Hennen’s benefits, she sued under ERISA, arguing that Metlife’s determination that she did not have radiculopathy was arbitrary and capricious.  The court hearing the case had granted summary judgment in favor or Metlife.  This appeals court reversed the ruling saying Metlife acted arbitrarily when it discounted the opinions of four doctors who diagnosed Hennen with radiculopathy in favor of one physician who ultimately disagreed, but only while recommending additional testing that Metlife declined to pursue.

The relevance of this case to all ERISA cases and attorneys who attempt to help clients with these cases is how, at least in part, this case was won.

When one realizes that these cases have very little to no discovery other than the claims file being given to the claimant, it is realizing what happens prior to the lawsuit being filed that is important.

In ERISA cases, the job of the Federal Judge is to review the claims file to see if the claims administrator has abused the discretion given to the claims administrator to make claims decisions.  This review is limited to the contents of the claims file.  The plan administrators are given broad discretion and their decisions will not be overruled absent an abuse of their discretion.

So what becomes important is documenting the claims file at the time of the making the claim or when seeking an administrative appeal of an adverse ruling.  Coming up with evidence supporting the administrators decision after the appeals are exhausted is simply too late.

In this case the claims file has documentation from four qualified doctors supporting Hennen’s claim.  This documentation in the claims file is vital for someone seeking to overturn an adverse decision of a claims administrator.

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