The Level of Review from an Administrator’s Denial, Could be Determinative of the Outcome of Your LTD Lawsuit.

The Level of Review from an Administrator’s Denial, Could be Determinative of the Outcome of Your LTD Lawsuit.  Once again, a recent Circuit Decision turned on the level of review afforded to the administrator of an ERISA plan.  In Gross v. Sun Life, decided August 16, 2013, the First Circuit reversed the district court’s grant of summary judgment to Sun Life finding that the court applied the wrong standard of review to the denial.  Sun Life argued on appeal that the district court correctly found that a deferential standard of review, the arbitrary and capricious standard, should apply because of two statements in the policy: “Proof [of claim] must be satisfactory to Sun Life” and “Benefits are payable when Sun Life receives satisfactory Proof of Claim.”  The Appeals Court then discussed an existing split in the circuits relating to what language is sufficient in a ERISA Plan to trigger a deferential review before concluding, “[h]aving now fully considered the issue, we agree with those courts holding that the “satisfactory to us” wording, without more, will ordinarily fail to meet the “requisite if minimum clarity” necessary to shift from de novo to deferential review.”

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