In Texas, a claimant’s ability to challenge a denial of disability benefits depends on many factors, not the least of which is whether the disability insurance policy is governed by ERISA. Another critical factor is having a good lawyer: a Texas disability attorney must have considerable experience in handling ERISA disability denials to have any chance of either winning an Appeal or convincing a judge to reverse a disability claim denial. While not every disability policy is governed by ERISA, the majority are and being prepared is critical.
Texas Passes Law Banning Discretionary Clauses in Disability Policies
Every ERISA disability denial lawsuit begins with consideration of whether the disability insurance policy contains a “discretionary clause,” which is nothing more than insurance company language written to give them the right to interpret certain terms of the disability policy and make a final claim decision. Many insurance companies try to build this kind of language into policies to limit claims and to restrict a court’s ability to overturn insurance company decisions. With a discretionary clause, the court must defer to the insurance company and can only reverse the denial if it is “arbitrary and capricious.” However, if a disability policy does not contain a discretionary clause, then a court is not restricted in their review of a disability claim denial.
“As of January 1, 2012, the State of Texas passed a law which prohibits any insurance company from issuing or selling a disability policy which contains a discretionary clause. The Texas law banning discretionary clauses only applies to disability policies issued or renewed after Janaury 1, 2012″.
A Texas Court’s Review of a Claim Denial
The Fifth Circuit Court of Appeals – Texas’ highest federal court – explained the “arbitrary and capricious” standard of review in the case of Firman v. Life Insurance Company of North America. That case involved a dispute over insurance benefits. The plaintiff’s husband died in single-vehicle accident. The police report indicated that his truck veered off the street when entering a curve and then he overcorrected, causing the truck to rollover. Without a seatbelt, he was partially ejected out of the passenger window and crushed by the truck. He died instantly. Toxicology tests showed he had alcohol in his system at the time of the crash.
The widow filed a claim for insurance benefits under two Group Accident Policies. Although both policies were accidental death policies, neither defined the term “accident.” While the policies excluded coverage for injuries from certain activities, they didn’t contain any exclusion for deaths resulting from intoxication or the use of controlled substances. But both policies gave LINA (also known as CIGNA) “full discretionary authority to administer and interpret” the policies.
LINA denied the claim on the ground that the incident was not an accident. In its view, the deceased would have been aware of the risks involved in operating a vehicle under the influence and, for this reason, his death was a foreseeable result of his actions and not an accident. In fact, LINA announced a rule that driving while intoxicated automatically precludes a finding of an accident under any circumstance.
The Texas Court’s Basis for Overruling Cigna’s Denial of an Accidental Death Benefit Claim
The Fifth Circuit Court of Appeals found that LINA / CIGNA had improperly denied coverage. Even though the policy gave LINA the right to make some decisions, the Fifth Circuit Court of Appeals determined that the decision to deny coverage could not stand. The court said that LINA could not assume that all alcohol-related deaths are automatically foreseeable and therefore non-accidental. Some alcohol-related incidents may be foreseeable, while others may not. LINA’s categorical approach was fundamentally unreasonable. The court’s decision was bolstered by the way LINA handled the claim including:
- LINA had a conflict of interest, as the insurance company was both the claims administrator and the source of funds for paying claims;
- LINA offered no evidence, other than the blood-alcohol content, to contradict the argument that the incident was an accident; and
- LINA misrepresented the severity of the intoxication by comparing the deceased’s urine-alcohol content to the legal limit for blood-alcohol content.
Ultimately, the court characterized LINA’s actions as arbitrary and capricious, which resulted in an order requiring LINA to pay the insurance benefits to the widow.
Firman v. Life Insurance Company of North America, No. 11-20451, 2012 WL 2161135 (5th Cir. June 15, 2012)