Firm Wins Client Right to Full and Fair Review of Disability Claim
Plaintiff Joel Helfman, a construction company owner and supervisor suffered from a long history of cardiac related problems. By-pass surgery in December of 2004 rendered him unable to continue working due to stress. Helfman, who was then insured under two disability policies, applied for and initially received benefits from both insurers. However, eventually both insurers terminated benefits for different reasons. Defendant Sun Life determined that Helfman was no longer disabled and could return to work, despite Plaintiff’s cardiologist’s adamant concerns that the stress of returning to work posed too great of danger to Helfman’s health. Helfman appealed the decision with Sun Life but Sun Life refused to reinstate Helfman’s benefits. Helfman then sought legal counsel with FHWN.
Attorneys J. Laevin Weiner and Tamara Fraser of FHWN filed suit on Helfman’s behalf, challenging Sun Life’s termination of benefits. Because the trial court determined that Helfman’s policy was governed under ERISA and because the policy at issue vested the insurer with discretion, the court could only reverse Sun Life’s termination of benefits if it found that Sun Life’s review was ‘arbitrary and capricious’. The trial court found that Sun Life’s review was not arbitrary and capricious.
Helfman then appealed the lower court’s decision to the U.S. Court of Appeals for the Sixth Circuit. The three-judge panel unanimously ruled that, in fact, Sun Life’s termination of Helfman’s benefits was arbitrary and capricious. In its opinion, the panel stated, “Sun Life did not engage in a deliberate and principled reasoning process.” The appellate court remanded the case to the lower court with instructions to remand the claim back to Sun Life for a full and fair review.
Because the arbitrary and capricious standard of review is such a big hurdle to overcome, it is very difficult for most insurance claimants to win a reversal when their benefits have been terminated or denied. FHWN attorneys will continue to assist Helfman in seeing that his claim is fully and fairly reviewed this time by Sun Life.
Attorneys J. Laevin Weiner and Tamara Fraser of FHWN filed suit on Helfman’s behalf, challenging Sun Life’s termination of benefits. Because the trial court determined that Helfman’s policy was governed under ERISA and because the policy at issue vested the insurer with discretion, the court could only reverse Sun Life’s termination of benefits if it found that Sun Life’s review was ‘arbitrary and capricious’. The trial court found that Sun Life’s review was not arbitrary and capricious.
Helfman then appealed the lower court’s decision to the U.S. Court of Appeals for the Sixth Circuit. The three-judge panel unanimously ruled that, in fact, Sun Life’s termination of Helfman’s benefits was arbitrary and capricious. In its opinion, the panel stated, “Sun Life did not engage in a deliberate and principled reasoning process.” The appellate court remanded the case to the lower court with instructions to remand the claim back to Sun Life for a full and fair review.
Because the arbitrary and capricious standard of review is such a big hurdle to overcome, it is very difficult for most insurance claimants to win a reversal when their benefits have been terminated or denied. FHWN attorneys will continue to assist Helfman in seeing that his claim is fully and fairly reviewed this time by Sun Life.