Last week, the Fifth Circuit Court of Appeals held that the administrator of an occupational injury benefit plan subject to ERISA did not abuse its discretion in denying disability coverage to a worker where the evidence supported the basis for its denial. In Jurasin v. GHS Property & Casualty Insurance Co., 2012 WL 612559 (5th. Cir. Feb. 27, 2012), an injured worker sought long-term disability benefits under his employer’s occupational injury benefit plan for injuries to his neck allegedly sustained during work. After a medical review officer determined, and the appeals board confirmed, that the employee’s work-related injuries were limited to his thoracic and lumbar spine and did not include a pre-existing neck condition, the employee filed suit under ERISA’s civil enforcement provision challenging the denial of benefits for his neck condition.  The district court granted summary judgment in favor of defendants, Caprock Claims Management (plan administrator) and GHS Property & Casualty Insurance Co. (insurer), which the employee appealed.

Reviewing the district Court’s decision to grant summary judgment de novo, the Fifth Circuit appeals panel looked to whether there was some evidence to support the administrator’s decision to deny benefits, even if that evidence was disputable. The Court found evidence to support the administrator’s decision to deny benefits related to the worker’s neck and found no evidence that the plan administrator acted arbitrarily or capriciously. The Court further acknowledged there was some evidence that the employee’s work accident worsened his neck condition but that such evidence was not enough for reversal.

The  Court  also  determined  that  there  was  no evidence  of  a  conflict  of  interest,  as  claimed  by  the employee.  Although Caprock Claims Manager served as both the evaluator and payor, there was no evidence that Caprock’s dual role affected the benefits decision.

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