AN ERISA INSURER OR ERISA PLAN MUST SUFFICIENTLY EXPLAIN ITS DENIAL
June 20, 2017
When an insurance company or ERISA plan denies your disability claim, it often leaves you with more questions than answers. You will likely receive a letter littered with conclusions as to why you are not disabled without any reasoned explanation as to why you do not qualify. The law is clear, however, that an ERISA insurer or ERISA plan cannot properly base its denial on a medical consultant’s conclusion where that conclusion is unsupported by a reasoned explanation.
One example of the multiple times in which courts have stated that an ERISA insurer cannot deny a claim without a reasoned is the meticulously reasoned decision from the Northern District of California, James v. AT&T W. Disability Benefits Program, 41 F. Supp. 3d 849, 874-875 (N.D. Cal. 2014).
In James, Judge William Orrick found that the ERISA administrator’s denial was arbitrary and capricious for many reasons, including the failure of the Plan’s experts to provide reasons to support their opinions. As Judge Orrick stated:
Dr. Lewis [the physician retained by the Claims Administrator] also said that a sedentary occupation would not “cause undue levels of pain” for James despite the fact that Dr. Balytsky [a treating doctor] concluded that James could not sit for more than 15 minutes at a time without experiencing pain. AR 745. But he does not explain how he reached any of these conclusions. Id. at 875.
The Court also stressed that the ERISA administrator’s denial was arbitrary and capricious because it failed to identify evidence that demonstrated that the claimant was able to work. As the Court stated:
… But the plan did not point to any affirmative evidence supporting its argument that James was actually able to work. Without “rely[ing] on other contradictory evidence,” the plan abused its discretion by failing to identify “reliable evidence that conflicts with [the] treating physican[s’] evaluation.” Farhat, 439 F. Supp. 2d at 973; Rowell, 2012 U.S. Dist. LEXIS 67201, 2012 WL 1672497, at *15. James v. AT&T W. Disability Benefits Program, supra at 877 (Emphasis added.)
If your disability claim has been denied, it is important to carefully review the denial letter to see whether the ERISA administrator or insurance company has actually set forth a reasoned explanation based on evidence as to why you are not disabled. The failure to provide a reasoned explanation may convince a federal judge to reverse the denial and order the payment of disability benefits.
-Posted June 20, 2017 by Bennett M. Cohen