ERISA-Fifth Circuit Upholds Denial Of Claim For Reinstatement Of Disability Benefits, Despite Doc’s Change Of Opinion

In Crowell v. CIGNA Group Insurance, No. 09-51086 (5th Circuit 2011), the plaintiff had been covered under his employer’s long-term disability plan (the “Plan”). The Plan was insured by defendant Life Insurance Company of North America (“LINA”), and LINA had been appointed a fiduciary of the Plan, with the full discretion to decide benefit claims, and to interpret the Plan. The plaintiff had been receiving long-term disability benefits under the Plan due to heart problems. However, LINA decided to discontinue the benefits, and the plaintiff brought suit under ERISA to have the benefits reinstated. The district court granted summary judgment for LINA, and the plaintiff appealed.

The Fifth Circuit affirmed the district court’s ruling. Applying a deferential review to LINA’s decision to discontinue the benefits (due to LINA’s discretionary authority to decide claims) , the Court found that LINA’s decision was based on substantial evidence. This evidence outweighed any potential conflict of interest from LINA’s serving as claims decider and benefit payer.

One key issue: During 2005, the plaintiff’s cardiologist, Dr. Rodney Brown, provided LINA with information that the plaintiff’s condition had improved and that he would be able to return to work without restriction starting late in 2005. In early December 2005, LINA received more information from Dr. Brown, confirming his earlier prognosis that Crowell could return to unrestricted work in late 2005. However, in early January 2006, Dr. Brown sent another letter to LINA, in which he expressed a contrary opinion. According to the January letter, the plaintiff could not return to his original position. Dr. Brown did not provide any medical records, evaluations, examinations, or tests in support of his contrary opinion. Therefore, since it appears that the contrary opinion was not based on any new examination or evaluation, the Court disregarded the contrary opinion in the January 2006 letter. Additionally, the Court noted that the January 2006 letter did indicate that the plaintiff was capable of working enough hours per week so that he was not considered disabled under the Plan. This afforded a second reason for determining that this letter does not support plaintiff’s claim.

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