What is contra proferentem? Carlile v. Reliance Standard Life Insurance Co.[1] is a textbook illustration of the doctrine that construes ambiguities in insurance policies in favor of the insured and against the insurer. In February, the U.S. Court of Appeals for the Tenth Circuit affirmed a ruling by the U.S. District Court for the District […]
The most critical issue in Employee Retirement Income Security Act benefits litigation is the standard of judicial review applied by the courts. Under the deferential arbitrary and capricious standard of review, the court reviews a claim record compiled by the insurance company[1] to determine whether a claim denial was “downright unreasonable”[2] and not merely wrong. Because […]
In Ariana M v. Humana Health Plan of Texas, Inc., 2018 WL 1096980 (5th Cir. March 1, 2018), a divided Fifth Circuit issued an en banc ruling that finally overturned Pierre v. Conn. Gen. Life Ins. Co., 932 F.2d 1552 (5th Cir. 1991) and concurred with every other Circuit that Firestone Tire & Rubber Co. v. […]
A recent decision issued by the U.S. Court of Appeals for the Fifth Circuit illuminates the importance of the standard of judicial review applied to resolution of cases seeking benefits under ERISA. In Ariana M v. Humana Health Plan of Texas, Inc., 2017 WL 1423765 (5th Cir. April 21, 2017), although the court of appeals […]
A recent ruling from the 1st U.S. Circuit Court of Appeals upheld an insurance company’s denial of health-care benefits for psychiatric treatment. Although the underlying facts are compelling, the most interesting aspect of the ruling was the court’s discussion of civil procedure and judicial standards of review under the Employee Retirement Income Security Act. The […]
Because federal courts generally consider the scope of their review of an ERISA benefit denial as being limited to review of a record, what happens if significant material evidence such as a Social Security determination becomes available only after the claim appeals are exhausted. If the standard of judicial review is arbitrary and capricious, it […]