Court upholds insurer's second-guessing of doctor's long-term disability

David B. Cox was awarded long-term disability insurance and Social Security disability after suffering an event which his neurologist described as a stroke.  After paying benefits for two years, the ERISA insurer, Standard Insurance Company, "reevaluated" Cox's disability and determined that he could return to the practice of Family Medicine.  Cox filed an administrative appeal, which was denied, and then filed suit in Federal Court to challenge the decision.

Because his policy was part of an ERISA employee-benefit plan, the Sixth Circuit applied a "highly deferential arbitrary and capricious standard of review" to the insurer's decision.  It noted the obligation to temper this deferential review by taking cognizance of the inherent conflict of interest involved in Standard determining whether it would pay benefits out of its own pocket.

Applying this standard to the medical documentation presented by Cox, the Court rejected his disability claim.  It noted that the company was not bound by the decision of the Social Security Administration.  It further noted that there was medical evidence to support the insurer's doctors' opinions that Cox was able to work, and therefore the insurer's decision was "based on a 'principled and deliberative reasoning process' ".