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Douglas Max Robinson's Legal Cases (2)

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Employee benefits

Smith v. Continental Casualty Co., 616 F.Supp. 2d 1286 (N.D.Ga. 2007)

Jul 16, 2017

OUTCOME: Claimant awarded remand

This published decision is notable for the Court’s ruling that a surgical error, although a known and common risk of the procedure, nevertheless constitutes an “accident” to establish coverage under an ... accidental death and dismemberment insurance policy. The decision is also notable for its holding that “Sending an insured a medical report containing new reasons for claim denial and simultaneously declaring an end to the administrative process before those reasons can be tested is the sort of ‘gamesmanship [that] is inconsistent with full and fair review’ [required by the ERISA regulations.]” This second principle of ERISA law has now been codified in the amended ERISA claim regulations for disability cases which apply to claims filed after April 1, 2018.

Employee benefits

Madison v. Greater Georgia Life Ins. Co., 225 F.Supp. 3d 1381 (N.D.Ga. 2016)

Dec 21, 2016

OUTCOME: Benefit denial overturned finding abuse of discretion

Successfully overcame adverse opinions from one prior treating physician and three paid medical consultants to reverse insurer's denial of benefits under ERISA's arbitrary and capricious standard of pr ... oof by showing medical consultants "cherry-picked" the record and failed to acknowledge objective findings in functional capacity evaluation (FCE). Case is cited by other lawyers for the objective reliability of FCEs and the holding that regardless of the number of medical reviews an insurer obtains, if those physicians ignore or discount credible evidence they do not support denial of the claim.