The standard of review in a benefits case often drives the outcome. This was illustrated in a recent Middle District opinion: Dowling v. Metropolitan Life Insurance Co.
Courts recognize three standards of review. The “pure arbitrary and capricious” standard of review is highly deferential to the Plan. The “heightened arbitrary and capricious” standard of review governs where the claims decision maker operated under a conflict of interest. Under Eleventh Circuit precedent, it is presumed that this conflict infected the decision unless the decision maker can show otherwise. Thus, less deference is given to the Plan under this standard. Finally, the “de novo” standard of review gives no deference to the Plan. Which standard governs depends on whether the Plan included adequate protective language in plan documents, as well as the afore-mentioned presence (or not) of a conflict of interest. More on this in a later post.
In Dowling, Judge Moody noted that the plaintiff’s own treating physicians were equivocal and that the defendant’s consultants found that he could perform sedentary work. The Court held that the pure arbitrary and capricious standard of review applied. Not surprisingly, the Court upheld the benefits denial.
Plaintiffs can win “pure arbitrary and capricious” cases but seldom if ever without the unequivocal help of the treating physicians.