The United States Court of Appeals for the Ninth Circuit recently ordered a lower court to reconsider its decision that had affirmed Hartford Financial Insurance Company’s denial of a woman’s claim for disability benefits. Although the claimant has not yet been awarded her requested disability benefits, the Appeals Court’s decision leaves her one step closer to achieving this goal.
The Appeals Court remanded the case of Janice Parker back to the lower court for two reasons:
- The lower court reviewed Hartford’s disability benefit denial with the wrong standard of review; and
- The lower court failed to consider the policy’s mental nervous disorder limitation.
De Novo Review Ordered:
In ERISA cases, the default standard of review is “de novo” unless the governing disability policy grants discretion to the insurance carrier. When the insurance carrier is given discretion by the policy to interpret the policy and to decide whether benefits should be awarded, the court’s hands are tied in deciding only whether the insurance carrier abused this discretion. Although there may be sufficient evidence to support a finding of disability, if discretion lies with the carrier and there is a reasonable explanation for the administrator’s decision denying benefits, then the decision must be upheld by the court.
Conversely, when the policy does not grant discretion to the carrier, the appropriate review conducted be the court is the “de novo” standard. This standard allows the court to look at a disability plan administrator’s decision with a more critical eye. The court has the right to look at the evidence and evaluate whether the plan administrator’s decision was right, not just reasonable. Disability claimants would prefer the court to review the carrier’s decision under the de novo standard.
In the case of Janice Parker, the lower court conducted a review of Hartford’s decision under the abuse of discretion standard rather than conducting a de novo review. The Court of Appeals found that the lower court used the incorrect standard because the language in the disability policy only stated that the claimants were entitled to “a full and fair review” of their claims. The Court noted that this language did not mention nor grant discretion, and as such, the lower court should have use the de novo standard of review.
Ambiguous Mental Disorder Limitation in Hartford Disability Policy:
Janice Parker’s policy stated that the carrier would “not cover any loss caused by or resulting from a disability beyond 24 months after the elimination period if it is due to mental or emotional disorder of any type.” Because Janice Parker had been on claim for more than 24 months, the lower court felt that her benefits for mental and emotional disorders were exhausted and thus the mental disorder limitation was not implicated. The Court of Appeals disagreed.
The Court of Appeals found that the mental disorder limitation was implicated when Hartford refused to consider Parker’s previously acknowledged mental disabilities because of the limitation. Furthermore, the Court of Appeals found the limitation language in this specific disability policy to be ambiguous because it was not clear whether a disability was to be classified as “mental” by looking to the cause of the disability or to its symptoms or whether a disability resulting from a combination of physical and mental factors is included in the limitation. The Court stated that because ambiguities in the policy language are always construed against the drafter (here, as in most insurance cases, the carrier), Janice Parker’s illness would not fall under the limitation language if a physical illness contributed to, or was a cause or symptom of, the mental disorder. In other words, if Janice Parker’s depression caused her physical symptoms or if her physical problems contributed to her depression, she would still be entitled to benefits.
Because the lower court used the incorrect standard of review and failed to consider the mental disorder limitation or apply the correct definition of that limitation, the Court of Appeals remanded the case back to the lower court for a new review. Hopefully this disability claimant will receive long term disability benefits beyond 24 months.