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My client’s cause for an ERISA accidental death and dismemberment denial lawsuit—and the painstaking fight for justice that came with it—began on a clear July day in 2014. During a drive with her husband David, both Esther and her husband were involved in a tragic head-on collision with an 18-wheeler. This tragic accident resulted in severe injuries to Esther, as well as David’s untimely death.
David had a great job and often worked overseas. Because of the security this position provided, David was the sole breadwinner for himself and Esther. In acknowledgment of this responsibility, David had taken out a very expensive accidental death and dismemberment insurance policy with CIGNA to protect his family.
This policy fell under a federal law known as the Employee Retirement Income Security Act (ERISA), which would eventually provide the procedural framework for Esther’s claim. However, when tragedy struck, Esther was shocked to find that the very policies her husband worked hard to finance for their protection were not there to protect Esther when she needed it most.
David’s hard work and dedication to his family was seemingly dismissed out of hand in a CIGNA denial letter, which claimed David’s blood and urine samples proved he was intoxicated at the time of the crash and that the accident report stated he was impaired. What they did not include, however, was their own internal evidence contradicting this very conclusion.
This letter made it clear that CIGNA was not going to give Esther the financial security David worked for. As her attorneys, it was our job to work on her behalf and help her get justice for herself and David both through an ERISA accidental death and dismemberment insurance denial lawsuit.
In accordance with ERISA procedure, Esther first filed an initial appeal to CIGNA’s denial. Under ERISA, a beneficiary may appeal a denial through the “administrative appeal” process. In appealing this decision, Esther and I requested “any and all documents you may rely on toward making your decision [on coverage]” in hopes that CIGNA would provide us with all the evidence they had that lead them to their denial. They did not.
This appeal was fruitless as it affirmed CIGNA’s initial denial. What was not clear at this moment was a glaring conflict of interest and buried internal evidence that contradicted CIGNA’s own decision.
In response to CIGNA’s continued refusal to provide Esther with her rightful benefits, we filed an ERISA denial lawsuit of David’s accidental death and dismemberment policy against CIGNA in federal district court in August of 2015. CIGNA answered this complaint and filed the administrative record with the court.
The filing of administrative records is a unique aspect of ERISA law. Specifically, it restricts the scope of the evidence before the court to the evidence contained within this administrative record filing, which is the evidence the insurance company used to reach their denial. Although this slimming of the scope of the evidence often favors insurance companies, CIGNA’s filing revealed a smoking gun: contradictory evidence from CIGNA’s own internal report.
CIGNA had, on two separate instances, neglected to produce upon request an internal medical report which contradicted their claim that David was “impaired” and “intoxicated” at the time of the crash. This report should have been provided in both the denial letter and in the production of “any and all documents” request we submitted.
Their report found that “the drugs present in [David]’s urine only show that he had prior exposure and cannot be used to estimate a level of impairment.”
Despite this new-found evidence, the magistrate judge issued a recommendation in CIGNA’s favor, citing “substantial evidence” in the record to support CIGNA’s denial. Despite our objections, the district court entered judgment for CIGNA, adopting the magistrate’s recommendations.
In the face of this third consecutive defeat, our zealous advocacy for Esther did not relent. We appealed to the U.S. Fifth Circuit Court of Appeal and finally found justice. The Fifth Circuit found that CIGNA “abused its discretion in denying benefits” based on four different pieces of evidence.
The first consideration the Court made was CIGNA’s conflict of interest that manifested within their denial. This was not a hard conclusion to make—as the opinion for the case states, “Indeed, [CIGNA] concedes it has a conflict of interest.”
The second aspect of the case the Court considered was CIGNA’s failure to address their contradictory internal report in its denial of benefits to Esther. The court agreed with our arguments, finding that this omission constituted “procedural unreasonableness.” This “procedural unreasonableness” further supported us as “[it] justifies the court in giving more weight to the conflict.”
The third consideration the Court took under advisement centered around a violation by CIGNA in the procedural rules relevant to ERISA denials. Under 29 U.S.C. § 1133, employee benefit plans governed by ERISA must “afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review.” We argued in our lawsuit that this duty to provide a “full and fair review” was not met. The Court agreed, finding that CIGNA “did not substantially comply with ERISA’s procedural requirements and, consequently, denied [Esther] a ‘full and fair review.’”
The final element presented before the Court was the question of whether CIGNA’s denial was supported by “substantial evidence.” The Court conceded that CIGNA’s decision was supported by relevant evidence, but this fact was outweighed by CIGNA’s conflict of interest.
All of these considerations combined led the court to conclude that they could not uphold CIGNA’s decision. The Fifth Circuit Court remanded the case with instructions to enter judgment in our favor, representing the end to our and Esther’s long-fought legal battle.
This case is just one of many that demonstrates the philosophy of the Law Offices of J. Price McNamara: fighting for justice and holding insurance companies accountable. This case represents one of many examples of the injustices that plague ERISA law and lead to lawsuits over ERISA denials.
If your ERISA benefits have been denied, you should contact a lawyer who is experienced in ERISA cases immediately to begin the fight for a positive outcome. Call today to get started on your case.
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