Experience. Results.

A lesson in persistence when challenging ERISA claim denials

On Behalf of | Nov 29, 2022 | ERISA

Resolute determination resulted in a recent court victory in an ERISA denial case. In Collier v. Lincoln Life Assurance Co. of Bos., the plaintiff’s attorneys overcame denials from both plan administrators and a district court judge to revive their client’s claim for benefits. Here’s a summary of the case.

The plaintiff was forced to stop working after suffering orthopedic impairments that could not be relieved through therapy, surgery or ergonomic accommodations. A claim for ERISA benefits was submitted with an accompanying doctor’s report, which was denied by Lincoln Life, the plan administrator, without elaboration.

An appeal with additional evidence was submitted to Lincoln Life and denied, arguing that the plaintiff could still work even with their acknowledged pain and limitations. With no more appeals available, the plaintiff escalated the case to the district court.

The district court ruled in favor of Lincoln Life, noting that much of the plaintiff’s argument was based on pain complaints alone, not tangible medical evidence. The court also agreed with Lincoln Life that the plaintiff could still reasonably work with the help of ergonomic equipment.

The case was kicked up to the Ninth Circuit Court, who, in a lengthy ruling, singled out Lincoln Life’s initial denial, which did not address the plaintiff’s credibility or even offer an actionable explanation for the denial. In its ruling, the Ninth Circuit overruled the district court’s decision, saying it had erred by allowing Lincoln Life to submit after-the-fact arguments for the initial denial.

In essence, the district court allowed Lincoln Life to move the goalposts during litigation. The Ninth Circuit cited similar, successful appeals (namely Mitchell v. CB Richard Ellis Long Term Disability Plan, Harlick v. Blue Shield of Cal., and Wolf v. Life Ins. Co. of N. America) supporting its ruling that such post hoc arguments aren’t admissible, neither during a denial appeal nor in a subsequent court setting.

However, the Ninth District declined the plaintiff’s request to rule on the claim itself, sending the case back to the district court for another chance at “‘ review[ing] the administrative record afresh to determine whether Lincoln correctly denied Collier’s claim,’ without ‘rely[ing] on rationales that Lincoln did not raise in the administrative process to deny benefits.'”

This reinforcement of settled law regarding the introduction of new evidence in court that had previously not been shared by plan administrators in a denial is an encouraging victory for claimants. It’s also an effective tool for attorneys representing plaintiffs in the ever-evolving realm of ERISA law.