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Fort Lauderdale Florida Insurance Law Blog

DI Law Group Successfully Halts Liberty Mutual's Attempt to Terminate Disability Benefits with an IME

Ms. "Jones" contacted DI Law Group after being advised by her representative at Liberty Mutual that her claim was being reviewed under the "any occupation" definition of her Long Term Disability Policy. At the time Ms. Jones became disabled she was a full time Registered Nurse whose primary duties involved the hands-on medical care of her patients. As the result of Fibromyalgia and Chronic Pain Syndrome, Ms. Jones was forced to stop working in 2015 and applied for disability benefits under her employer's Long Term Disability Policy provided to her as a benefit of her employment with the hospital. After a lengthy claim review and several strong statements of support from her physician, Ms. Jones claim for LTD benefits was approved. Specifically, it was determined that as the result of her chronic pain she was unable to perform the duties of her occupation, an RN.

The Southern District of Florida Finds that the PNC Plan Fails to Properly Delegate Discretion to Liberty Life Assurance Company and Finds that the Plan's Denial of Benefits to a Branch Manager Disabled by Degenerative Disc Disease Was Wrong

In a recent case out of the Southern District of Florida, the district court held that while the PNC Plan provided PNC with discretion to determine questions of coverage and eligibility for benefits, there was not a proper grant of discretion to the third-party administrator who actually made the claim decision, The Liberty Life Assurance Company ("Liberty Life"). The court explained that although the Plan permitted PNC to delegate its discretion to another party, the Plan did not contain a clear and unambiguous grant of discretion to Liberty Life. The court rejected PNC's argument that it properly granted Liberty Life discretion in a separate, Administrative Services Agreement ("ASA"), explaining that the ASA was not a plan document and the discretionary language in the ASA was not appropriate to cloak Liberty Life's decisions with full discretionary authority. Accordingly, the court determined that the de novo standard of review applied, rather than the more stringent, arbitrary and capricious standard of review. The court also determined that the denial of disability insurance benefits was de novo wrong and must be overturned.

Life Insurance Interpleader Actions can be Filed in Court by Insurance Companies as a Lawsuit or as a Crossclaim or Counterclaim

Many times, an interpleader action is pursued by a life insurance company after two or more individuals file a competing life insurance claims for the same death benefit that is only required to be paid once under a life insurance policy. A life insurance company usually pursues an interpleader action in court by initiating a lawsuit as a plaintiff, whereby it sues all individuals who may have a claim to the life insurance benefit at issue as defendants to the lawsuit, and lets the claimants litigate who is entitled to the money at issue. The court then decides which claimant prevails, which has the effect of the insurance company avoiding a risk of double liability to more than one claimant.

Eleventh Circuit Court of Appeals Finds that Reliance Standard Life Insurance Company Acted Unreasonably When it Denied Disability Insurance Benefits Under the Pre-Existing Condition Exclusion to a Woman Who Suffered a Stroke Nine Days After Giving Birth

Julissa Bradshaw had a healthy pregnancy and no other pre-existing medical conditions when she became insured under her ERISA governed disability insurance policy with Reliance Standard Life Insurance Company ("RSL"). Approximately six months after obtaining the policy, Julissa gave birth to her daughter. Tragically, nine days later, Julissa suffered a debilitating stroke and was unable to return to work. Accordingly, Julissa filed a claim for long-term disability benefits with RSL. RSL denied Julissa's claim, alleging that her healthy pregnancy qualified as a pre-existing condition that "contributed to" her stroke. RSL argued that the Policy permits RSL to deny long-term disability benefits for a total disability that was "caused by," "contributed to by," or "resulting from" a pre-existing condition unless the insured has been actively at work for a full year. RSL claimed that because Julissa had not been employed for a full year, was pregnant during the "look-back period," and her pregnancy "played a part in producing" the stroke, her pregnancy "contributed to" her stroke and was therefore excluded from coverage.

Fourth Circuit Court of Appeals Finds Bert Bell/Pete Rozelle NFL Player Retirement Plan was Wrong and Unreasonable When it Denied a 9 Year NFL Veteran with Traumatic Brain Injury Total and Permanent Disability Benefits

In May of 2017, we discussed the case of Jesse Solomon v. Bert Bell/Pete Rozelle NFL Player Retirement Plan, where the district court held that the NFL Plan was wrong and unreasonable when it denied Total and Permanent Disability ("TPD") benefits to Jesse Solomon, a nine year veteran of the NFL with traumatic brain injury. Since that time, the NFL Plan appealed the decision to the Fourth Circuit Court of Appeals, which upheld the district court's decision that the NFL Plan acted arbitrarily and capriciously.

Federal Circuit Court of Appeals Holds that a Return of Life Insurance Premiums Paid After the Death of an Insured is Insufficient When an Insured Continued to Pay Premiums with the Understanding there was Continued Life Insurance Coverage

In the recent case of McCravy v. Metropolitan Life Insurance Company, 690 F.3d 176 (4th Cir. 2012), the Fourth Circuit Court of Appeals determined that a return of life insurance premiums to Mrs. McCravy after her daughter's death was insufficient where Mrs. McCravy continued to pay premiums through the date of her daughter's death with the understanding that there was continued life insurance coverage for her daughter. The Court ruled that under these circumstances, Mrs. McCravy was entitled to pursue her claims for the full life insurance benefit promised to her under the life insurance policies that she paid continued premiums for until her daughter's death.

Liberty Life's Wrongful Denial of Disability Benefits for Bipolar Disorder and Carpal Tunnel Syndrome

In the case, Suson v. The PNC Financial Services Group, INC., No. 15-CV-10817, 2017 WL 3234809, at *1 (N.D. Ill. July 31, 2017), Liberty Life Assurance Company of Boston, acting as the Plan administrator for PNC's ERISA disability plan, denied long term disability benefits to Ms. Suson who was diagnosed with bipolar disorder in 1996 and had received regular psychiatric treatment since 1990. She had also been treated for bipolar disorder and diagnosed with fibromyalgia and several other degenerative joint diseases for which she received regular treatment. Ms. Suson filed her claim for long term disability benefits on July 24, 2014. She initially based her claim for benefits on bipolar disorder but on September 3, 204 advised Liberty Life that she was also disabled due to fibromyalgia and physical limitations. Liberty denied Suson's claim for LTD benefits on October 8, 2014 stating that the records did not "reasonably support" that she had any "impairments attributable to the presence of mental illness that would preclude" her from working. Ms. Suson appealed the adverse determination and Liberty upheld its denial.

Cigna Continues to Engage in Unreasonable Delay and Denial Tactics of Disability Insurance Claims, Including Alleging that Disabling Conditions are Pre-Existing, After Cigna was Forced to Overturn Denials Under Similar Circumstances

In 2003, Susan Kristoff was diagnosed with breast cancer. After undergoing treatment, it was determined that she was in full remission and cancer free. As a precautionary measure, she was placed on Tamoxifen to prevent the recurrence of cancer in the future. Later, Susan was hired as an outside salesperson for a large corporation and obtained a disability insurance policy with Cigna through her employment. Susan continued to undergo regular evaluations and each time, her physicians assured her she remained cancer free.

Court of Appeals Rules Against Reliance Standard Life Insurance Company and Upholds an Award of Disability Insurance Benefits Under ERISA Policy, Costs, and Attorneys' Fees.

In a recent case, Marcin v. Reliance Standard Life Insurance Company and Mitre Corporation Long Term Disability Insurance Program, No. 16-7125, __F.3d__, 2017 WL 2818648 (D.C. Cir. June 30, 2017), the Court of Appeals for the District of Columbia, ruled against Reliance Standard Life Insurance Company and upheld an award of benefits, costs, and attorneys' fees under an ERISA governed disability insurance policy for a claimant, Jill Marcin. Ms. Marcin suffers from multiple medical conditions including kidney cancer, portal vein thrombosis, Factor V Leiden (a mutation of one of the clotting factors in the blood called factor V which, increases the chance of developing abnormal blood clots, usually in the veins - including pulmonary embolisms), splenorenal shunt, polycystic ovarian syndrome, and anemia.

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