Ariana M. v. Humana Health Plan of Texas, Inc.

The Fifth Circuit granted en banc review of this case to reconsider Pierre v. Conn. Gen. Life Ins. Co., 932 F.2d 1552, 1562 (5th Cir. 1991), and to determine the default standard of review that applies when a beneficiary challenges a plan denial based on a factual determination of ineligibility. The court held that the Texas insurance code provision only renders discretionary clauses unenforceable, but does not attempt to prescribe the standard of review for federal courts deciding Employee Retirement Income Security Act (ERISA) cases. The court overruled Pierre and held that Firestone Tire & Rubber Co. v. Bruch's, 489 U.S. 101, 115 (1989), default de novo standard applied when the denial was based on a factual determination. The court held that Vega v. National Life Insurance Services, Inc., 188 F.3d 287 (5th Cir. 1999), will continue to provide the guiding principles on the scope of the record for future cases that apply de novo review to fact-based benefit denials. Therefore, the court vacated and remanded for the district court to apply the de novo standard of review. View "Ariana M. v. Humana Health Plan of Texas, Inc." on Justia Law