Court Opinion

ID: 9494091
Source: CourtListenerOpinion
Date Created: 2023-08-05 15:29:10.585667+00
Date Added: 2024-06-11T17:56:12.978187
License: Public Domain

HEANEY, Circuit Judge,
dissenting.
I respectfully dissent. While it is clear that an ERISA suit is premature until a claimant has exhausted available administrative appeals, I disagree with the majority’s conclusion — apparently without precedent in this circuit — that the administrator’s initial reason for denying benefits is irrelevant. Under the majority’s analysis, the underlying medical issues of any disputed disability claim will never receive judicial scrutiny in an ERISA action to recover benefits if the policy defines disability to exclude those who are working, unless the insured has sufficient resources to forgo any income whatsoever until the claim has found its way through the administrative appeals process to the courthouse. This is particularly troubling where, as here, the claim is that the occupation itself is the source of an employee’s worsening and life-threatening illness.
I agree that there are sound policy reasons for requiring a claimant to exhaust administrative appeal procedures. Those considerations, however, do not counsel that the administrator be permitted to conceal an initial medically-based decision behind the insured’s subsequent return to work out of economic necessity. I would therefore remand for the district court to review Prudential’s medical determination that Galman’s continued work as a trial lawyer did not jeopardize his health such that he was disabled under the plan.