This week’s notable decision is another terrible decision for ERISA plan participants out of the Fifth Circuit Court of Appeals:  Ariana M. v. Humana Health Plan of Texas, Inc., No. 18-20700, __F.App’x__, 2019 WL 5866677 (5th Cir. Nov. 8, 2019) (“Ariana II”).  This is a disappointing sequel in a case where the Fifth Circuit previously issued a plaintiff-friendly decision on the standard of review applied in ERISA cases.  The case first reached the Fifth Circuit in Ariana M. v. Humana Health Plan of Texas, Inc., 884 F.3d 246 (5th Cir. 2018) (“Ariana I”) in which the court issued an en banc published decision overturning the longstanding position on standard of review in Pierre v. Conn. Gen. Life Ins. Co., 932 F.2d 1552, 1562 (5th Cir. 1991).  The court reversed and remanded the case to the district court for review under a de novo standard of review. (Read more about Ariana I in Brent Dorian Brehm’s Fall 2017 EBC Newsletter article: What Does de novo Review Mean Under ERISA?) Continue Reading Fifth Circuit Denies Attorneys’ Fees to Plaintiff for en banc Success Changing Judicial Standard of Review

For those of us waiting for a court to follow the reasoning in the remarkable Wit v. United Behavioral Health, 2019 WL 1033730 (N.D. Cal. Mar. 5 2019) decision earlier this year, we got it last week with the decision in S.B. v. Oxford Health Ins., Inc., No. 3:17-CV-1485 (MPS), __F.Supp.3d__, 2019 WL 5726901 (D. Conn. Nov. 5, 2019). In sum, Judge Michael Shea found that Oxford’s denial of a 16-year-old’s residential treatment for an eating disorder was arbitrary and capricious and remanded to Oxford for further consideration. 

To start, the court did not accept Plaintiff’s argument that a de novo standard of review should apply because United Behavioral Health Services, Inc. (“UBH”), not Oxford, made the benefit determination. Plaintiff contended that although UBH made the benefit determination, there is no indication that the Plan gives UBH discretionary authority. The court found that the Plan language contemplates the delegation of authority to third parties with the definition of “Us, We, Our” which included not only Oxford but also anyone to whom Oxford “legally delegate[s] performance,” including UBH.  Continue Reading District Court Finds Oxford’s Denial of Teen’s Residential Treatment Arbitrary and Capricious Due to Reliance on UBH Guidelines

This week’s notable decision is Card v. Principal Life Insurance Company, No. 18-6095, __F.App’x__, 2019 WL 5618182 (6th Cir. Oct. 31, 2019), where the Sixth Circuit concluded that Principal Life Insurance Company was arbitrary and capricious when it denied Plaintiff Card’s claim for disability benefits.  

Card was a registered licensed practical nurse who worked the night shift providing patient care and supervising nursing assistants.  In February 2013, a specialist in hematology/oncology diagnosed her with chronic lymphocytic leukemia, a type of blood and bone marrow cancer.  Over the following six months, Card began experiencing a worsening of symptoms, including night sweats, fatigue and exhaustion.  Bloodwork showed an increase in Card’s white blood cell count and lymphocytes.  She could not afford to see the specialist again nor afford more bloodwork as recommended by her primary care physician.  Though her doctor recommended disability, Card continued to work with accommodations.  She stopped working in December 2013 due to fatigue and weakness that left her feeling unable to perform her job.   Continue Reading Sixth Circuit Revives Nurse’s Disability Benefit Claim Against Principal Life Insurance Company