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Enforcing ERISA Procedural Requirements

The Fifth Circuit has systemically addressed the requirement that claim administrators comply with ERISA regulatory rules, and the consequences when they do not do so. When a claim administrator fails to substantially comply with ERISA's procedural requirements, the Fifth Circuit remands the case to the claim administrator for a full, fair review.

Common procedural violations included:

  • The claim administrator raised new grounds for denial in court that were not raised to the administrative level;
  • The claim administrator did not identify the medical reviewer relied upon despite the claimant's request for this information;
  • The claim administrator relied upon the same medical reviewer for an opinion in the initial denial and in the administrative appeal; and
  • The claim administrator relied upon a medical reviewer who lacked the appropriate training and experience in the medical field involved and gave deference to the initial denial.

The Fifth Circuit is the only circuit which has explicitly recognized that when a review is for abuse of discretion, even when the claim administrator has substantial evidence to support its decision, that decision can be an abuse of discretion if there are sufficient procedural irregularities. Thus, the Court found that even though there was substantial evidence to support a denial of benefits, the denial of benefits was an abuse of discretion because of the severe procedural irregularities committed by the insurance company.

Even though the claimant was awarded benefits, however, the Fifth Circuit reversed the district court's award of attorney fees to the successful claimant, reasoning that "the legal questions in the case are much closer than the district court credited, and the district court, therefore, abused its discretion in assessing attorney fees against the insurance company." Again, this is a sign that despite its capability to make good law, its overall judicial temperament can be quite conservative.

Serving the Fifth Circuit

Our ERISA attorney serve the Fifth Circuit by representing claimants in the following states and cities: Louisiana: New Orleans, Baton Rouge, Shreveport, Metairie, Lafayette, Lake Charles, Kenner, Bossier City and Monroe; Mississippi: Jackson, Gulfport, Southaven, Hattiesburg, Biloxi, Meridian and Tupelo; and Texas: Houston, San Antonio, Dallas, Austin, Fort Worth, El Paso, Arlington, Corpus Christi and Plano.