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Court in Fifth Circuit Applies De Novo Review in Long Term Disability Case

By Amar Raval May 20, 2019 Posted in News & Events

At Berg Plummer Johnson & Raval, we monitor cases that affect our clients’ rights, including those involving long term disability claims. The following case shows how the Fifth Circuit’s new way of reviewing ERISA cases, changed in Ariana M. v. Humana in 2018, is applied in district court.

The case of Pike v. Hartford Life and Accident Insurance Company, __F.Supp.3d__, 2019 WL 1375178 (E.D. Tex. Mar. 27, 2019) is one of the most extensively briefed disability cases under the new de novo standard of review. Ms. Pike suffered from chronic back pain and degenerative disc disease, After eight years of paying the claim, Hartford terminated it, arguing that Ms. Pike was now able to work in other occupations. After the parties submitted their briefs and participated in a 2 hour oral hearing, the Court issued a detailed opinion in favor of Ms. Pike. Hartford then filed 5 main objections: (1) the report misstated the insurance policy’s definition of “disability”, (2) the report relied on old medical records to support its conclusion that Ms. Pike was still disabled, (3) the report applied a “treating physician rule” that favored Ms. Pike’s physicians over Hartford’s, (4) the report relied on Ms. Pike’s subjective complaints of pain instead of “objective medical evidence”, and (5) the report improperly “cherry-picked” from the administrative record.

The Court rejected all of Hartford’s arguments. In doing so, it cited to evidence that it found more probative than Hartford’s evidence. The Court also cited to cases that explained the nature of de novo review and how it is to be applied in this context. Under de novo review, its role is to independently weigh the facts and opinions to determine if Ms. Pike met her burden to show she was disabled under the terms of the Hartford policy. Hartford’s previous decision to terminate Ms. Pike’s claim did not get any deference. This means the Court must resolve material questions of fact, assess expert credibility, and weigh the evidence.

What’s the takeaway lesson? The ripples from Ariana M. continue to resonate in the district courts. Insurance companies who deny disability claims are no longer getting the benefit of doubt, and courts are making independent determinations. This helps further the goal of ERISA, which is to protect the interest of employees.

Contact a Houston Disability Insurance Lawyer Today

If you have had your legitimate disability insurance claim wrongfully denied by an insurer, undervalued, or unreasonably delayed, then it’s important to get in touch with an experienced Texas disability insurance attorney here at Berg Plummer Johnson & Raval, LLP for assistance. With the aid of a qualified attorney, you can effectively and timely appeal the denial of benefits. If the internal appeal is unsuccessful, we are prepared to represent you in court.

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