As a practical matter, an insurance claimant fighting an ERISA life or accidental death insurance intoxication clause denial on administrative appeal or in court without the help of a seasoned ERISA attorney is ill-advised. But that doesn’t mean you can’t win. It just means you may need help.
The reason an ERISA attorney’s help is advised is that ERISA law is complex, and some of the arguments you need to make to be successful are very technical.
The legal battle in an ERISA case, done right, can also be very tedious and time-consuming. The fight requires a ton of work from the time of the insurance company’s initial denial, through the administrative appeal process, through judgment at the district court level, then finally through judgment at the appeal court level. And the insurance companies typically hire several attorneys who specialize in ERISA law from some of the largest law firms in the country to fight the claimant’s attorney every step of the way.
Our client’s case, summarized above, is a perfect example of the amount of work that can be required to beat an insurance company who argues an intoxication defense. We took a loss on administrative appeal to CIGNA. Then we took another loss at the district court level, meaning the district court judge agreed with CIGNA’s lawyers on the intoxication exclusion defense.
It wasn’t until after taking an appeal to a three-judge panel of the U.S. Fifth Circuit Court of Appeal that my client finally received justice. All told, bringing our client’s case to a successful conclusion took hundreds of hours of work in researching and briefing the facts from an administrative record over 1000 pages long. It took finding the one critical toxicologists report that CIGNA first withheld, buried deep in that record. It took meeting with the Coroner to secure his testimony clarifying his comment made on the death certificate. It took researching and arguing the law to four judges in two separate court proceedings. And at the formal Fifth Circuit court hearing (called “oral argument”), where the attorneys make their arguments in open court to the judges, who pepper them with questions, comments and arguments about their positions, it was hard to tell whose position the judges actually favored. It was certainly nerve-racking for our client, who watched it. It wasn’t until the Court’s formal opinion landed in our email inbox a couple of months later that we could tell our client the good news.
Most claimants have no real way to know what goes into researching, briefing and arguing an ERISA life or accidental death insurance intoxication exclusion case to the court.
So to give claimants some real-world perspective, we’ve reproduced in full our opening brief and reply brief filed in our client’s case with the U. S. Fifth Circuit Court of Appeals below.
If interested, you can also listen to the oral argument by clicking this link.
You can Google White v. Life Insurance Company of North America (CIGNA), 892 F.3d 762, 5th Cir.(La.), June 13, 2018, as revised (Jun 14, 2018) to read the full court opinion.
The Fifth Circuit’s judgment was a just ending for our deserving client, no doubt, but CIGNA should have simply paid the benefits it owed her without withholding critical evidence and putting her through a ridiculous fight. It would have saved court resources, attorney’s fees on both sides and much delay and distress for a grieving widow.
Unfortunately, unfair ERISA insurance claim denials won’t end anytime soon.
The most powerful tool we have at our disposal to help curb abuse is public awareness.
My client’s hope is that her story will be shared, ultimately spread to insurers across the country and hopefully curb rampant insurance company abuse.
And she also hopes that her experience will be shared with others to empower people who are victims of that abuse to keep fighting and never give up their hope for justice.
So please share her story with others.
Please also share with us any unfair insurance claim denial stories you know or have experienced.
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