On September 22, 2008 the Fifth Circuit issued its decision in Young v. Wal-Mart Stores, Inc., et. al.

The case involved an ERISA claim for accidental death and dismemberment (AD&D) benefits in the amount of $25,000. The decedent suffered from a history of severe hypertension. He stopped taking his medication, became very ill and began vomiting profusely and choked to death. The policy provided an exclusion for losses related “in whole or in part from…sickness.”

Sickness was defined as “illness or disease diagnosed by a physician.” The district court awarded Plaintiff benefits holding that the choking death was an “accident”. The Fifth Circuit reversed holding that there was substantial evidence in the record to support the plan administrator’s decision that the death resulted, in part, from “sickness”. The significant thing about the opinion has to do with standard of review.

The court has an extensive discussion of MetLife v. Glenn and states:

In the present case, there is no evidence of biased claims administration. Nor is there any evidence that AI Life failed to provide its independent expert with all relevant evidence. On the other hand, there is no evidence that AI Life has “walled off claims administrators from those interested in firm finances.” AI Life did not emphasize any report over another, but its decision to deny benefits reflects that it did not accept an opinion expressed by Earl Young’s treating physician. We nevertheless conclude that on balance, based on the record as a whole, the conflict of interest factor is not of great importance.

The court further states “although this inquiry into the facts is to be searching and careful, the ultimate standard of review is a narrow one.  The court then concludes that the record before it contains “substantial evidence” to affirm the administrator’s claim denial:

“The job of weighing valid, conflicting professional medical opinions is not the job of the courts; that job has been given to the administrators of ERISA plans.” The administrative record contained substantial evidence, “even if disputable,” that supports the plan administrator’s denial of benefits.  Based on that evidence, and taking into consideration the minimal conflict of interest, AI Life did not abuse its discretion in denying benefits.

The court reversed the district court’s grant of benefits. The Fifth Circuit’s Young opinion simply reaffirms what I think has been the trend over the last two (2) months, and that is that post Glenn courts are merely reaffirming what had previously already been the law in the majority of circuits.  Thus far, it appears as if Glenn really only substantially changed the law in the Eleventh Circuit.

That case stands for the proposition that the court’s task is not to simply find supporting evidence somewhere in the record, but to review the complete administrative record to determine if the decision was well-informed or whether additional information was needed.

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This entry was posted by Adam V. Russo on Friday, September 26th, 2008 at 2:02 pm and is filed under 5th, News. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.