The Fifth Circuit Court of Appeals recently reversed summary judgment for plan participants in an ERISA matter. Dupre v. Employee Benefit Servs. of La., Inc., No. 09-30990 (5th Cir. Sept. 2, 2010), available at http://www.ca5.uscourts.gov/opinions/unpub/09/09-30990.0.wpd.pdf.
Jennifer Dupre, a morbidly obese woman, planned to have gastric bypass surgery and sought coverage under the ERISA plan offered by her husband’s employer. The plan granted the administrator authority to interpret the plan, and the administrator refused payment because the plan disallowed coverage for obesity-related procedures. The Dupres sued, and the district court granted summary judgment for the Dupres.
Where a plan expressly confers discretion on the administrator to construe the plan’s terms, the administrator’s decision is reviewed under an abuse of discretion standard. The Court must first determine the legally correct interpretation of the plan and then determine whether the administrator’s interpretation accords with the legally correct interpretation. If not, the Court must determine whether the administrator’s interpretation constitutes an abuse of discretion. Crucial to this determination is whether the administrator’s interpretation is fair and reasonable. Because a reasonable interpretation could find that the planned surgery was connected to obesity and because the administrator made a determination after considering all the relevant evidence, the Court upheld the administrator’s decision and reversed the judgment for the Dupres.
To speak to a Dallas labor and employment lawyer about ERISA, contact the employment law firm of Clouse Dunn Khoshbin LLP at [email protected].
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