Analysis of 59 Long-Term Disability Cases in 4th Circuit Court
At BenGlassLaw, we analyzed all ERISA long-term disability cases decided by a trial or appellate court in the 4th Circuit over the last three years—59 cases total as of the date of publication. The 4th Circuit comprises Maryland, Virginia, West Virginia, North Carolina, and South Carolina, which is where most of our cases are handled.
Our analysis revealed that insurance companies won approximately 50-60% of the cases, often due to the court deferring to the insurer’s discretion under the “abuse of discretion” standard. (In court, “abuse of discretion” is a term used to describe when a judge makes a ruling that is not reasonable, legal, or supported by evidence.) However, in the remaining 40-50% of cases, claimants won by successfully challenging the insurer’s interpretation of plan terms, biased medical evaluations, and procedural violations.
Notably, some of the key victories for claimants were achieved in cases handled by our firm. In Aisenberg v. Reliance Standard Life Insurance Co., the court initially sided with the insurer, but in the most recent opinion, we secured a major victory for the claimant, with the court rejecting the insurer’s arguments and awarding substantial benefits. Similarly, in both Wonsang v. Reliance Standard Life Insurance Co. and Cogdell v. Reliance Standard Life Insurance Co., we successfully challenged the insurance companies’ denials, winning significant benefits for our clients.
These cases underscore the importance of a strong legal strategy from the beginning, especially during the administrative appeal, where arguments and evidence must be carefully built to withstand insurer tactics.
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Top 5 Reasons Courts Rule in Favor of Long-Term Disability Insurance Companies
The administrative appeal is often where ERISA cases are won or lost. Without an experienced disability lawyer guiding you through the process, it’s easy for claimants to make critical errors that insurers exploit in court. Based on our analysis of 59 ERISA cases in the 4th Circuit, here are the top five reasons courts rule in favor of insurance companies—and why you need experienced legal representation from the moment your claim is denied.
1. Failure to Provide Medical Evidence
One of the most common reasons courts rule in favor of insurance companies is the claimant’s failure to present objective medical evidence. Chronic conditions like pain disorders, migraines, or fibromyalgia often lack clear-cut diagnostic tests, and without strong medical records backing your claim, you’re at a disadvantage. Courts often defer to insurance companies when the evidence is weak or lacking.
Case example: Penland v. Metropolitan Life Ins. Co. – The court ruled against the claimant because there wasn’t sufficient objective medical evidence to support the disability claim.
Why it matters: The administrative appeal is your last chance to get the right evidence into the record. If you don’t submit thorough medical documentation during this stage, the court won’t allow you to add new evidence later. Once you’re in court, it’s too late to strengthen your case. A skilled long-term disability lawyer ensures your evidence is airtight from the very beginning.
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2. Courts Defer to the Insurance Company’s Discretion
ERISA cases are unique in that courts often defer to the insurance company’s discretion when interpreting plan terms, especially if the plan grants the insurer broad authority. Even if you have a strong claim, if you fail to challenge the insurer’s interpretation during the administrative appeal, you may be stuck with their interpretation in court. Courts generally won’t allow you to introduce new arguments about how the plan should be interpreted once you’re in litigation.
Case example: Montour v. Hartford Life & Acc. Ins. Co. – The court upheld the insurer’s denial because the judge found the company’s interpretation of the plan to be within their discretion.
Why it matters: The administrative appeal is your only chance to challenge the insurer’s interpretation of your plan. If you don’t properly dispute their reading of the policy, you could be locked into their version when the case goes to court. An experienced attorney ensures that every issue—especially the interpretation of key plan terms—is challenged during the appeal, protecting your right to make those arguments later.
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3. Biased Medical Reviews Favoring the Insurer
Insurance companies frequently rely on “independent” medical evaluations that dismiss a claimant’s disability, particularly when the condition is based on subjective symptoms like chronic pain or fatigue. These “experts” are often handpicked by insurers for their willingness to side against claimants. Many are doctors who no longer treat actual patients, are unqualified to assess the specific condition, or have a financial incentive to minimize claims.
However, courts have recognized that these evaluations can’t always be the sole basis for denial, especially for conditions where objective evidence is hard to come by.
Case example: DuPerry v. Life Insurance Co. of North America – The court ruled in favor of the claimant, finding that the insurer’s reliance on biased, non-treating doctors who dismissed fibromyalgia and chronic fatigue as subjective was unreasonable.
Why it matters: During the administrative appeal, you have the chance to expose these unqualified and biased doctors and challenge their conclusions. An experienced attorney will help uncover these fake experts and present additional evidence of their bias and inexperience. Without this crucial step, courts are often left with nothing to counter the insurance company’s experts. Having a legal team that knows how to discredit these biased opinions can make all the difference in your case.
4. Misinterpretation of Plan Language
One of the most underhanded tricks insurance companies use is twisting the language of your long-term disability insurance plan to deny your benefits. The administrative appeal is the crucial stage where you need to challenge the insurer’s interpretation of the plan. During this process, you should be analyzing how courts have interpreted similar language in other cases involving the same company and plan. This kind of legal research and argumentation is critical to your success but is something a person handling the appeal on their own—or an inexperienced attorney—likely won’t be able to do effectively.
Case example: Montour v. Hartford Life & Acc. Ins. Co. – The insurer’s interpretation of “any occupation” was upheld because it wasn’t adequately challenged.
Why it matters: The administrative appeal is your only chance to submit arguments about how your plan should be interpreted. A skilled ERISA long-term disability attorney will dig into past court decisions involving the same company and plan to make powerful arguments backed by legal precedent. Without that level of expertise, you could be locked into the insurer’s interpretation in court. An experienced ERISA long-term disability litigator knows how to challenge these interpretations effectively, ensuring that the right arguments are made and the best legal precedents are applied.
5. Procedural Errors in the Administrative Process
ERISA has strict procedural rules that you must follow during your administrative appeal. Missing a deadline, failing to submit key evidence, or not addressing certain issues can doom your case. But procedural requirements cut both ways—insurance companies must also follow strict Department of Labor regulations when reviewing and denying claims. An inexperienced attorney, or a claimant handling the appeal on their own, may not realize that the insurance company violated these rules. Courts will uphold the regulations if the right arguments are made—but only if your attorney knows how to identify and exploit these procedural failures.
Case example: Penland v. Metropolitan Life Ins. Co. – The claimant lost because crucial evidence was missing from the administrative record, and the court would not allow it to be introduced during litigation.
Why it matters: An experienced ERISA attorney can undercut the insurance company’s decision by identifying procedural violations that could invalidate the denial. This requires a deep understanding of Department of Labor regulations governing ERISA claims. Insurance companies rely on claimants going it alone—or hiring inexperienced attorneys who won’t spot these mistakes. By ensuring that every violation is exposed, we can strengthen your case and improve your chances of success.
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