The Fifth Circuit chastised the Life Insurance Company of North America (LINA), a CIGNA company, for playing this game.
Facts of the Case
- The decedent, David White, was driving down the highway one afternoon when his car went straight on a curve resulting in a head-on collision with an oncoming truck.
- The beneficiary, Edith White, was a passenger in the vehicle at the time.
- David was still alive at the accident scene.
- Paramedics claimed that there was alcohol on David's breath and a trooper took a blood sample.
- At the hospital, David also provided a urine sample. The hospital's toxicology analysis found the test was negative for alcohol, but positive for amphetamines, cocaine, opiates, benzodiazepine, and cannabinoids. The reports, however, only confirmed the presence of the drug and not the amount. No additional testing was done.
- David later died from a massive stroke brought on by his injuries.
- Edith filed a claim for life insurance benefits, which LINA denied contending an intoxication exclusion applied since David had ingested substances at some point.
- Suit was filed, and the district court agreed with LINA.
- However, the district court had glossed over the fact that LINA had withheld a critical report during the claim process.
- Dr. Fochtman had written a report, honestly noting that, because there was no testing as to the level of intoxication, it was impossible to evaluate whether the insured was intoxicated. Thus, it was impossible to determine if the presence of the various drugs affected David at all.
- LINA, however, refused to make this evidence known and did not produce this report during the claim process. Instead, it ignored the report and manufactured other reasons to deny the claim.
- The Fifth Circuit did not like this ‘game' and found that, as a matter of law, there was no proof that David was intoxicated or under the influence.
Assumptions are nothing more than speculation, and that constituted an abuse of discretion. The Court particularly noted that LINA's conflict-of-interest affected the benefit decision, and, so, in accordance with the Supreme Court's direction in MetLife v. Glenn, it not only reversed the decision but instructed the district court to enter judgment in Edith White's favor. White v. Life Insurance Company of North America, No. 17-30356, __F.3d__, 2018 WL 2978641 (5th Cir. June 13, 2018).
The game played here of “hiding the ball” or hiding evidence is seen in many cases with this insurer. Our decades of experience give us the tools necessary to note when an insurer is withholding documents. It takes hours of in-depth research into the claim record to ascertain this, but it is necessary in order to provide diligent and excellent representation.
Experience is a requisite to understanding of the claim process, the laws regulating that process, and knowledge of what should be in the claim record. This experience is an asset for our clients, who need to know when this game is being played.
The unfairness of ERISA is felt personally by deserving clients who are denied their benefit. We endeavor to correct this injustice, and it is nice to see that some courts will not play to these games.