In Burell v. Prudential Ins. Co., No. 15-50035 (5th Cir. 2016), plaintiff Patrick Burell (“Burell”) filed a claim for long-term disability benefits with defendant Prudential Insurance Company of America (“Prudential”). Prudential denied Burell’s initial claim and two subsequent appeals. Burell then filed suit against Prudential under ERISA, alleging that its denial of his long-term disability-benefits claim was in error. The district court granted summary judgment in favor of Prudential, and Burell appeals.
In this case, Burell was diagnosed with multiple sclerosis (“MS”) in 2008. Citing worsening symptoms of MS, in September 2011, Burell went on medical leave and filed for long-term disability benefits with Prudential under a plan covering him at work (the “Plan”), claiming that he qualified for benefits under the Plan due to MS, headaches, depression, and anxiety. In January 2012, he stopped working altogether. However, Prudential, who is the administrator and insurer under the Plan, denied his claim and the two appeals which followed.
In analyzing the case, the Fifth Circuit Court of Appeals (the “Court”) said, first, that the denial by Prudential is entitled to review under the abuse of discretion standard because the Plan grants Prudential the authority to interpret the Plan and make benefits decisions. The Court then said that it found no such abuse on the facts of this this case. Under the terms of the Plan, to qualify for the benefits claimed, Burell’s MS must render him unable to perform the material and substantial duties of his regular occupation. None of the health care providers consulted by Prudential found that Burell had physical or cognitive impairments. Therefore, Prudential was allowed to base its decision on the reports of its independent medical consultants, who found no such inability to perform, as opposed to Burell’s own physicians. Also, while Prudential has a conflict of interest since it is both administrator and insurer (payor), Burell has not shown how this affects the abuse of discretion analysis in this case.
Based on the above, the Court upheld Prudential’s denial of Burell’s claim for benefits, and affirmed the district court’s decision.