Burell v. Prudential Insurance Co. of America
820 F.3d 132
| 5th Cir. | 2016Background
- Patrick Burell, a long‑time Methodist Healthcare employee, claimed long‑term disability (LTD) benefits based on multiple sclerosis (MS), headaches, depression, and anxiety after stopping work in Jan 2012.
- The Plan (administered and insured by Prudential) required inability to perform material duties of regular occupation, doctor care, and ≥20% earnings loss.
- Prudential denied the initial claim after file reviews by an RN and a neurologist who questioned the MS diagnosis and found no disabling impairments.
- On two internal appeals Prudential engaged additional reviewers (psychiatry, neuropsychology, occupational medicine); some reviewers found no functional limitations, one confirmed MS but found no physical limits, and an independent neuropsychologist found no cognitive impairment.
- Burell filed suit under ERISA § 502(a)(1)(B) and (a)(3); the district court granted summary judgment for Prudential.
- The Fifth Circuit majority affirmed, applying abuse‑of‑discretion review because the Plan grants Prudential discretionary authority; a dissent argued genuine factual disputes remained and criticized Prudential’s procedures and handling of conflicting reviewer reports.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standard of review | District court should review de novo | Plan grants Prudential discretionary authority so abuse of discretion applies | Abuse of discretion review applies (Plan and SPD confer discretion) |
| Effect of administrator/insurer conflict | Structural conflict should change review or weigh against Prudential | Conflict is a factor but not dispositive; Prudential followed procedures | Conflict noted but did not show it affected decision; not enough to find abuse |
| Weight of treating physicians / SSA determination | Treating doctors and SSA award show disability; Prudential ignored them | Prudential reasonably relied on independent reviewers; SSA criteria differ from Plan’s | Prudential reasonably chose among competing medical opinions; treating opinions and SSA award insufficient to show abuse |
| Procedural irregularities and record completeness | Prudential failed to follow its review procedures and some reviewers lacked full files, creating disputed facts | Prudential’s review was thorough; any irregularities not flagrant or outcome‑determinative | Majority: no genuine dispute of material fact; dissent: procedural issues create genuine dispute warranting trial |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (LTD claims generally reviewed de novo absent plan discretion)
- Glenn v. Metropolitan Life Ins. Co., 554 U.S. 105 (structural conflict is a factor in abuse‑of‑discretion review)
- Holland v. Int’l Paper Co. Ret. Plan, 576 F.3d 240 (Fifth Circuit on discretionary language and conflict consideration)
- Truitt v. Unum Life Ins. Co. of Am., 729 F.3d 497 (conflict of interest is one factor; weight varies)
- Sweatman v. Commercial Union Ins. Co., 39 F.3d 594 (permissible choice between competing medical opinions)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (no special deference required to treating physicians)
- Gothard v. Metropolitan Life Ins. Co., 491 F.3d 246 (plan fiduciaries may adopt one of competing medical views)
- Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389 (review need only assure administrator’s decision lies on continuum of reasonableness)