Fifth Circuit overturns denial of benefits
Life insurance cases under ERISA can be difficult, because courts review the insurance company's denial under an abuse of discretion standard. Essentially, this means the courts consider whether the insurer had a reasonable basis for the denial, with substantial evidence in support. However, courts do not seek to determine if the insurer made the "right" decision. Furthermore, in ERISA cases there is no jury available to review the insurer's denial. This standard gives plenty of leeway for the insurer to find a reason to deny benefits.
In a recent case, however, the Fifth Circuit Court of Appeals overturned a district court's decision upholding Unum Life Insurance Company's denial of benefits. While the decision dealt with disability insurance instead of life insurance, the legal concepts at issue are similar in both contexts. The Fifth Circuit disagreed with the trial court that Unum had not abused its discretion. The Fifth Circuit appeared troubled that Unum pressured its consulting physician to rule that the claimant was not disabled, even though the physician was not provided with an MRI he had previously deemed important to review. Furthermore, Unum based its denial on opinions from its own paid physicians that were somewhat vague and certainly less than concrete.