ERISA-Fifth Circuit Rules That Plaintiff Is Not Entitled To LTD Benefits For A Neck Injury

In Jurasin v. GHS Property & Casualty Insurance Company, No. 11-50500 (5th Cir. 2012) (Unpublished Opinion), the plaintiff, John Jurasin (“Jurasin”), was seeking long-term disability (“LTD”) benefits for a neck condition he claims resulted from an accident during work. His employer provides an Occupational Injury Benefit plan (the “Plan”), which is subject to ERISA, and which provides LTD benefits. The Plan is administered by Caprock Claims Management (“Caprock”) and funded with an insurance policy issued by GHS Property & Casualty (“GHS”). Caprock informed Jurasin that his neck condition was not compensable under the Plan, since the work accident did not cause or excacerbate the neck injury. A review board also denied his claim. Jurasin brought suit, as a claim for benefits under ERISA (specifically under 29 U.S.C. § 1132(a)(1)(B)). However, the district court granted summary judgment to the defendants.

In analyzing the case, the Court said that when, as here, the administrator of an ERISA plan has discretion to determine eligibility and interpret plan terms, the administrator’s denial of a claim for benefits is reviewed for an abuse of discretion. The Court noted that it did not find any conflict of interest between the plan administrator, Caprock, and the Plan’s benefit payor, GHS, that could result in an abuse of discretion.

Jurasin had asserted that the district court erred by striking out supportive portions of his and his doctor’s affidavits. However, the Court responded by stating that evidence is irrelevant to the validity of the decision regarding plan coverage unless it is in the administrative record, relates to how the administrator has interpreted the plan in the past, or would assist the court in understanding medical terms and procedures. The Court found that the district court followed this rule carefully when striking those portions of the affidavits and admitting others. Further, the admitted evidence has indications that the neck injury was unrelated to the accident at work, and thus is not compensable by the Plan. There was admitted evidence to the contrary, but the plan administrator did not have to accept it in the face of other medical evidence. As such, the Court found that Caprock did not abuse its discretion in determining that Jurasin’s neck injury was not compensable by the Plan. Therefore, the Court affirmed the district court’s ruling.

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