Attorney for Fourth Circuit ERISA Cases
Serving Maryland, North Carolina, South Carolina, Virginia & West Virginia
If your ERISA case is heard in the U.S. Court of Appeals for the Fourth Circuit, how may this influence the outcome? At ERISA Law Center, our sole focus is disability and life insurance claims covered by the Employee Retirement Security Income Act of 1974 (ERISA). Through our time in practice, we have worked in all circuit courts and can offer insight that applies specifically to the Fourth Circuit: Maryland, North Carolina, South Carolina, Virginia and West Virginia.
Full and Fair ERISA Case Reviews
Fourth Circuit case law is good on the requirement for a full and fair review. In one case, the Court held that a plan administrator denied a fair appeal and that its decision was not the result of a deliberate principled reasoning process, supported by substantial evidence, where the administrator had noticed that the claimant had other illnesses which caused her health to deteriorate, but failed to address them. The Court reasoned that under the circumstances the administrator should have referred the claimant's appeal to a qualified doctor to assess her other conditions and not simply address one medical issue, which effectively resulted in the improper denial of her claim. The Court emphasized the need for consideration of all co-morbid conditions and consideration by a reviewer with appropriate experience and qualifications at the appeal level.
The Fourth Circuit also prohibits administrators from stating new reasons for denying benefits in an appeal denial but does give the plan/insurance company a "second chance." The Fourth Circuit reasoned that a new denial of benefits rationale in the appeal denial letter was, in fact, an initial denial. Therefore, the claimant was entitled by law to notice as to the new basis for denying her claim. Since the insurance company failed to provide that notice in its decision terminating benefits, it abused its discretion. However, the Court ordered that the matter should be remanded to the insurance company, but on remand, the insurance company could rely upon the new reason.