U.S. Fifth Circuit Reverses Denial of Life Insurance Benefits where Plan Administrator Fails to Address Beneficiary’s Expert Report

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Esther White was the beneficiary of her husband’s life insurance policies governed by ERISA, which contained exclusions where death is caused, at least in part, by “intoxication” as defined by Arkansas law, or by the “voluntary ingestion” of any “narcotic” or “drug” that is not prescribed by a physician. Coverage was denied by the Plan Administrator, and summary judgment was granted by the District Court.

Recognizing the insurance company’s inherent conflict under Glenn, the Fifth Circuit reversed: “It is undisputed that LINA did not address Dr. Fochtman’s report…. Dr. Fochtman’s report effectively stated that the level of the drugs in Mr. White’s system could not be determined, and thus whether the cause of Mr. White’s death was due to intoxication or drug abuse could only be speculative. The inability to determine the level of drugs in Mr. White’s system was critical to the application of the ‘intoxication’ exclusion because Arkansas defines ‘intoxicated’ as being influenced by alcohol or drugs ‘to such a degree’ that the driver is ‘a clear and substantial danger’ to himself and those around him. The inability to determine whether David was under the influence of alcohol or drugs at the time of the accident does not afford a reasonable conclusion that his death was caused by intoxication or drug abuse. Thus, LINA should have at least addressed the report in its denials, especially because Dr. Fochtman’s report was the only expert opinion in the record.”

 

White v. Life Insurance Company of North America, No.17-30356, 2018 WL 2974410 (5th Cir. June 14, 2018).

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