The federal District Courts are beginning to adjust their views on how to best handle ERISA denial-of-benefits cases. Some courts use a modified summary judgment standard unique to ERISA denial-of-benefits cases that are based exclusively on an administrative record and the non-moving party is generally not entitled to the usual inferences in its favor (unlike the traditional summary judgment standard). In Anderson v. Liberty Lobby, Inc., the Supreme Court stated that “at the summary judgment stage the judge’s function is not himself to weigh the evidence… but to determine whether there is a genuine issue for trial.” Therefore, if material facts are in genuine dispute, then summary judgment may not be appropriate. Some courts have concluded that when fact-finding is required, or there is genuine issue related to material facts, then a bench trial is best. The 4th Circuit has held that this situation may arise when there is a necessity “to resolve competing factual contentions within the administrative record about the cause, severity, or legitimacy of an individual’s impairment.” Tekmen v. Reliance Standard Life Ins., 55 F.4th 951, 960 (4th Cir. 2022) (citation omitted).
Of note, the 6th Circuit, which is relevant Kentucky, has discussed not using summary judgment procedures or bench trials to decide ERISA actions, but instead reviewing the merits of the action based solely upon the administrative record with findings of fact and conclusions of law. It was suggested that the courts only consider evidence outside of the administrative record for limited exceptions. Wilkins v. Baptist Healthcare Sys., 150 F.3d 609, 619 (6th Cir. 1998) (Gilman, J., concurring).
For example, when insurance companies try to determine whether or not to award disability benefits, they may seek to hire their own physicians to review the medical records on file to reach a determination. This determination may or may not conflict with the medical opinions of the treating physicians. When there are conflicting opinions between the physicians hired by the insurance company and the treating physicians, however, this will likely lead to material facts in dispute. This is when a bench trial may be the most appropriate way for courts to rule on ERISA denial-of-benefits cases. Like in the example outlined below:
In October of 2013, Anita Tekmen started new employment with Adsum, Inc., as a Financial Analyst. This position required “reasoning, cognitive exertion, and the ability to hear and understand easily.” Tekmen, 55 F.4th at 955. Simultaneously, through her new position, Ms. Tekmen received coverage under a long-term disability insurance policy provided by Reliance Standard Life Insurance Company. Unfortunately, Ms. Tekmen was involved in a rear-end car accident that drastically and negatively impacted her ability to continue working in her new position as a Financial Analyst.
Ms. Tekmen visited several physicians and specialists hoping to come up with a treatment plan that would ultimately see her return to work full-time. After her accident, however, Ms. Tekmen was unable to perform her work duties consistently and efficiently as she continued experiencing “dizziness, sensitivity to light and noise, and [had] difficulty concentrating.” Id. Despite her continued visits to specialists and treating physicians, Ms. Tekmen’s symptoms were worsening at a steady rate. Nearly two years later, Ms. Tekmen decided to file a claim for short-term disability benefits with Reliance and they granted her claim. Despite her best efforts, however, it became clear that Ms. Tekmen would not be returning to full-time employment as her symptoms continued to worsen.
Thus, two months after she submitted her claim for short-term disability benefits, she sought to convert her benefits into long-term disability benefits. Reliance denied Ms. Tekmen’s claim for long-term disability benefits and determined that she was not “Totally Disabled” as defined by her disability insurance plan. Ms. Tekmen brought an action under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. Section 1132(a)(1)(B). Ms. Tekmen argued that the denial of benefits violated ERISA. The district court conducted a bench trial in accordance with Federal Rule of Civil Procedure 52 and awarded judgment to Ms. Tekmen. The district court primarily relied on the medical opinions of Ms. Tekmen’s treating physicians to determine that she was “Totally Disabled” as defined by her disability insurance plan. Reliance appealed and the Fourth Circuit affirmed the lower court. The Fourth Circuit held that Ms. Tekmen was entitled to long-term disability benefits under the terms of the plan. By bringing an action under ERISA and moving for a bench trial in accordance with Federal Rule of Civil Procedure 52, Ms. Tekmen was able to eventually be awarded long-term disability benefits.
If you have questions about your benefits or have experienced a situation similar to Ms. Tekmen, call us today at (859) 225-3731 or visit us here to request a free consultation with one of Mehr Fairbanks’ attorneys.
*The information contained within this post should not be considered legal advice or legal representation.