Our client’s claim illustrates the typical procedural path for claims for insurance benefits governed by ERISA law after the insurance company initially denies a claim.
CIGNA persisted in its denial of benefits throughout the “administrative appeal” process required by ERISA law. The administrative appeal is where the insurance company basically takes a second look at its own initial claim denial. Throughout the process, CIGNA still never disclosed its toxicologist’s report despite written request on my client’s behalf for any such document. ERISA requires an insurance company who denies a claim to produce all evidence from its investigation to a claimant who requests it. But the insurance companies will sometimes withhold documents they are required to produce if the documents don’t support the denial of benefits.
ERISA law doesn’t allow a claimant to file a lawsuit until after taking an administrative appeal with the insurance company, which usually just results in another denial of benefits. So after CIGNA denied the administrative appeal, we filed suit in federal district court for wrongful denial of ERISA accidental death insurance benefits. CIGNA chose to hire and pay several attorneys from a large corporate law firm to fight against paying the widow’s claim. For the first time, CIGNA, through its attorneys, produced a stack of more than 1000 pages of documents from its investigation, never produced before. Its toxicology expert’s critical report, just a few pages long, was buried deep within it.
We presented this newly-revealed report to the unbiased Coroner, the physician who actually signed my client’s husband’s death certificate, and asked him for his opinion. The Coroner gave us a sworn statement, testifying in agreement with CIGNA’s own toxicologist, that the blood and urine samples could not support a finding of intoxication or impairment.
At that point, we hoped and really thought that reason would prevail once we shared this with CIGNA. We pointed out to CIGNA what its own expert and the Coroner said about impairment and intoxication, but even this didn’t change CIGNA’s mind. Remember, paying claims, whether legitimate or not, doesn’t help insurance company profits. CIGNA’s thought must have been that paying its attorneys to fight the court battle, if they could win, would be less expensive than paying benefits to a deserving claimant.
Believe it or not, citing ERISA legal technicalities, CIGNA’s lawyers told us that CIGNA wouldn’t even consider the unbiased Coroner’s affidavit because it had already completed its investigation. CIGNA’s attorneys then actually argued against letting the judge even consider the affidavit as evidence at trial. The attorneys cited to the ERISA technicality that the court can’t consider evidence that was not presented to the insurance company to consider during the administrative appeal process.
So we took the case to trial, but to my client’s dismay, the district court judge ruled in favor of CIGNA and against my client citing technicalities of ERISA law. A third gut punch.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts