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January 2015

Gordon & Rees Team Prevails before Tenth Circuit on ERISA Lawsuit

Gordon & Rees partner Sarah N. Turner and associate Brittany F. Stevens of Seattle, with the assistance of partner Franz Hardy and associate Ross Hoogerhyde, of Denver, succeeded in securing a judgment for the defendant insurer in the U.S. Court of Appeals for the Tenth Circuit after the plaintiff filed an appeal from the U.S. District Court for the Western District of Oklahoma upholding the denial of disability benefits.

The plaintiff alleged that she was unable to work at “any occupation” due to her long history of back pain. The insurer provided the plaintiff with short term and long term disability benefits for two years. Upon further evaluation of the plaintiff’s disability under the “any occupation” standard, the insurer found that she was no longer disabled. The district court reviewed the insurer’s decision under the abuse of discretion standard and found that the insurer took all necessary measures to void any inherent conflict of interest including hiring an independent physician to conduct an independent medical examination, performing a functional capacity evaluation, and conducting a home assessment. The district court further found that the medical records did not support the plaintiff’s claim that she was disabled from “any occupation.”

The plaintiff filed an appeal to the Tenth Circuit and, subsequently, Gordon & Rees filed a response brief arguing that the district court properly applied the arbitrary and capricious standard of review because there was no evidence of an inherent conflict of interest, and that substantial evidence supported the insurer’s denial of benefits. Gordon & Rees also argued that the insurer fully evaluated all of the records provided and evaluated the plaintiff’s disability based on the diagnoses given by her treating physicians, and produced any relevant documents to its expert reviewers.

In a thorough opinion issued December 3, 2014, the Tenth Circuit affirmed the district court’s decision to uphold the insurer’s denial of disability benefits under the “any occupation” standard. The Tenth Circuit concluded that the district court properly placed “diminished weight to [the insurer’s] dual-role conflict,” and properly evaluated the claim under an abuse of discretion standard of review. The Tenth Circuit noted that the insurer took steps to reduce bias by hiring independent physicians to evaluate the plaintiff’s alleged disability. The Court also concluded that the evidence in the record supported the insurer’s decision to deny disability benefits, but carefully evaluated whether there was procedural irregularity that rendered the insurer’s decision arbitrary and capricious. The Court found that the insurer properly presented the evidence to its own experts as the insurer received that evidence, and that the insurer’s physicians properly considered the plaintiff’s various medical conditions as presented by the medical records. The Court concluded by stating that the insurer “gave [the plaintiff] a full and fair opportunity to present her claim, conducted a procedurally reasonable review of the material evidence, and reached a decision supported by substantial evidence.”

The Gordon & Rees team and the client are pleased with the outcome particularly with the Tenth Circuit’s opinion finding that there was no inherent conflict of interest in the denial of the claim.

Franz Hardy
Sarah N. Turner