Although discouraged, our client let us continue the fight. Still firmly convinced that she was deserving and entitled to her benefits, we appealed the district court’s decision to the U.S. Fifth Circuit Court of Appeal, which is responsible for reviewing the decisions of all federal district courts in Texas, Louisiana and Mississippi.
There she finally received well-deserved justice. The Fifth Circuit reversed the district court in favor of this wonderful, brave and spiritual lady, ruled that CIGNA (Life Insurance Company of North America) must pay her claim. In other words, the court held that CIGNA’s intoxication exclusion didn’t apply.
and delivered a clear message to insurance companies: While insurance companies often get away with unfair claim denials under ERISA law, they will not get away with ignoring, or worse, like CIGNA did here, withholding key evidence to justify an abusive claim denial.
The Court explained (quoting from the Fifth Circuit’s written opinion of public record):
“LINA did not provide [its toxicologist’s] report to BLANK
…Importantly, although the letters of denial relied entirely on the toxicology results, the death certificate, and the amended collision report (which included the DWI citation), neither of LINA’s denials of coverage mentioned [the toxicologist’s] report…For the first time, BLANK
discovered [the] report in the documents LINA filed with the court…Thus, we consider LINA’s actual withholding of [the] report from BLANK
argues that LINA’s failure to provide her with [the] report, despite her written request for “any and all documents” LINA would “rely on toward making [its] decision,” violated ERISA’s procedural rules and thus denied …BLANK
a “full and fair review.”…Contrary to LINA’s assertions, [the] report undermines LINA’s position that intoxication or drug abuse was the cause of David’s death. Further, this opinion comes from the report of LINA’s very own expert. As such, without [the] report, during the administrative process BLANK
was unable to meaningfully challenge LINA’s finding that David’s death was caused by intoxication or drug abuse. We therefore conclude that LINA did not substantially comply with ERISA’s procedural requirements and, consequently, denied BLANK
a “full and fair review.”…
In sum, taking into account LINA’s conflict of interest, its procedural unreasonableness, its denial of a full and fair review, and the counter-balanced nature of the evidence, we hold that LINA abused its discretion in denying benefits… Accordingly, we reverse the district court’s judgment. We remand with instructions to enter judgment in favor of BLANK
and for such further proceedings as may be necessary and fully consistent with this opinion.
REVERSED and REMANDED.”
A PERFECT EXAMPLE OF WHY TO NEVER GIVE UP WHEN THE INSURANCE COMPANY CLAIMS THE INTOXICATION EXCLUSION BARS YOUR CLAIM
My client’s maddening story shows just how far insurance companies will go to deny a claim. It also illustrates how the insurance companies exploit the huge legal advantage given to them by many features of ERISA’s stacked (in their favor) deck. They often refuse to give in, and choose to hire attorneys, thereby forcing claimants to hire attorneys as well, until the court ultimately orders them to pay.
But her story also demonstrates that you should never just accept a life insurance or accidental death insurance company’s denial of benefits based on any policy exclusion as honest or legally correct. Justice can prevail despite the brutality of ERISA law. At the end of her legal battle, the Fifth Circuit’s written opinion delivers a clear message to insurance companies: While insurance companies often get away with unfair claim denials under ERISA law, they will not get away with ignoring, or worse, like CIGNA did here, withholding key evidence to justify a claim denial.