An insurance administrator acts arbitrarily and capriciously in violation of the Employment Insurance Retirement Security Act (ERISA)when he refuses to consider whether an employee’s risk of relapse into substance dependence swells to the level of a disability. An employer’s insurance company discontinued an employee’s disability benefits after she checked out of a rehabilitation facility where she lived while treating her opioid addition, although she remained under a doctor’s care after her discharge. According to D & H Therapy Associates, LLC v. Boston Mut. Life Ins. Co., the plan administrator’s determination must be reasoned and supported by substantial evidence. The Court of Appeals held that categorically excluding risk of relapse as a source of disability was unreasonable absent any language in the insurance plan that required such an exclusion.
Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack Anesthesia Assoc. Long Term Disability Plan, 705 F.3d 58 (1st Cir. 2013); D & H Therapy Associates, LLC v. Boston Mut. Life Ins. Co., 640 F.3d 27, 35 (1st Cir. 2011); Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001–1461. See also Julie Beck, Risk of Relapse into Addiction Counts as Current Disability, INSIDE COUNSEL, March 26, 2013, available at http://www.insidecounsel.com/2013/03/26/risk-of-relapse-into-addiction-counts-as-currnt-d; Ronald J. Kramer & James C. Goodfellow, First Circuit: Unwritten Risk of Relapse Exclusion is Unreasonable, Creates Split with Fourth Circuit, LEXOLOGY, Feb. 4, 2013, available at http://www.lexology.com/library/detail.aspx? g=f66441a1-a6a4-496c-9356-12e30eafb803.
(Development Authored by Nnenne Agbai)