The Third Circuit affirmed the District Court’s order that retroactively reinstated the plaintiff’s The Third Circuit held that an insurance company engaged in “procedural irregularities” when it used outside medical experts to overrule its in-house medical experts and terminated the participant’s disability benefits. The Court further held that those procedural irregularities aligned closely with the insurance company’s structural conflict of interest, so much so that the financial incentives at the core of the insurance company’s structural conflict influenced its fiduciary decision-making. The participant sued under the Employee Retirement Income Security Act. An employee participated in his employer’s long-term disability and life insurance benefits and eventually became disabled. Multiple times, the insurance provider’s in-house medical experts found the employee totally disabled, and then outside medical experts were hired who found that the employee was not permanently disabled. The Third Circuit held that the District Court correctly did not consider an affidavit that was not part of the administrative appeal process. The Court then held that the insurer had a structural conflict of interest because it makes benefits eligibility decisions and funds those benefits. Moreover, the timing of the insurance company’s use of outside experts was a procedural irregularity. Given the close alignment of the procedural irregularities with the financial incentives creating the structural conflict, the Court held that the insurer abused its discretion in terminating benefits. As such, the Third Circuit affirmed the District Court’s grant of summary judgment for the employee.
