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Court Denies Occupational Injury Benefits to Employee; 5th Circuit Affirms

Our client CHRISTUS Health Texas maintains an Occupation Injury Assistance Plan under the unique nonsubscriber provisions of Texas workers' compensation law. The Plan provides applicable benefits, including wage replacement benefits (WRB), to Plan participants who are temporarily totally disabled due to an occupational injury. It denied WRB to a nurse employed in its St. Michael Health System who claimed to have injured her back while lifting a patient because she submitted insufficient qualifying medical evidence to support her claim. The nurse filed an ERISA lawsuit in Texas federal court challenging the denial of her claim for benefits. We moved for summary judgment on behalf of the Plan, which the court granted, holding that there was substantial evidence in the record to support the Plan’s decision.

The nurse appealed and the 5th Circuit affirmed. It held that despite the nurse’s contention that the plan denied her access to doctors, interfering with the development of a complete and accurate medical record, she provided no legal support for her contention that the Plan was obligated to send her to multiple doctors for that purpose. The appellate court agreed that there was sufficient evidence in the record to support the Plan's determination that the nurse was ineligible for the benefits she sought.

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