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Fort Lauderdale Florida Insurance Law Blog

Traumatic Brain Injury LINA Claim Denial Reversed and found to be Arbitrary and Capricious

In the case of Van Steen v. Life Insurance Company of North America ,WL 256806 (10th Cir. Jan. 2, 2018) the Tenth Circuit, affirmed the district court's decision, finding that Life Insurance Company of North America's decision to terminate Mr. Van Steen's benefits was arbitrary and capricious. Mr. Van Steen was diagnosed with mild traumatic brain injury as the result of a physical assault. Initially he was prevented from working in any capacity. However, he was eventually cleared to return to work on a part time basis; but with noted limitations including the ability to rest frequently and work from home as necessary. At the time of his disability, Mr. Van Steen was employed by Lockheed Martin Corporation which provided disability coverage under the Lockheed Martin Group Benefits Plan. The short term and long term disability plans were both administered by Life Insurance Company of North America (LINA) and controlled by the Employee Retirement Income Security Act (ERISA).

Court Ruling on Mutual of Omaha Pre-Existing Denial of Benefits

In the case of Horneland v. United of Omaha Insurance Company, the eleventh circuit reversed the United States District court for the Middle District of Florida's decision finding for the defendant. In the case, Horneland sued United of Omaha Life Insurance Company under ERISA, due to the fact that United of Omaha Life Insurance Company denied Horneland's long term disability. Horneland began to work as a real estate manager for Thornton's Inc. as part of the employment, Horneland received short term and long term disability coverage. However, per United of Omaha Insurance Company's insurance plan, long term disability coverage begins on the day following completion of 12 months of Active employment. The long term disability benefits also include a Pre-existing conditions exclusion. That exclusion states that the insurance company will not provide benefits for disability (a) caused by, contributed to by, or resulting from a Pre-existing Condition; and (b) which begins in the first 12 months after the individual is continuously insured under the policy. The eleventh circuit defines the term pre-existing as any injury or sickness for which the individual received medical treatment, advice or consultation, care or services including diagnostic measures, or had drugs or medicines prescribed or taken in the 3 months prior to the day they become insured under the policy.

A Federal Court Overturns AETNA's Termination of Total Disability Benefits to a Claimant, finding that AETNA'S decision was Arbitrary and Capricious.

In a recent case, Patterson v. Aetna Life Insurance Company, No. CV 15-8156, 2017 WL 4786562 (D.N.J. Oct. 23, 2017), the United States District Court for the District of New Jersey, determined that Aetna's termination of Christopher Patterson's Long Term Disability Benefits was arbitrary and capricious. Mr. Patterson was employed by First Consulting Group, Inc. ("FCG"), which provided Long Term Disability Benefit coverage to its employees under the Long Term Disability group policy (the "LTD Policy"). The LTD Policy provided that disability occurs when an employee is unable to perform the material duties of their "own occupation" solely because of the disease or injury; and when the employee's work earnings are 80% less of their adjusted pre-disability earnings.

Attorney's Fees Granted for Sedgwick Arbitrary and Capricious Denial

In the case of Corey v. Sedgwick Claims Mgmt. Servs., et al., No. 1:15 CV 1736, 2017 WL 4844008 (N.D. Ohio Oct. 26, 2017), the Sixth Circuit remanded the case to the administrator for a "full and fair review." In this case, the Plaintiff was an employee for Eaton Corporation. As an employee, he was entitled to participate in the Corporations Disability Plan for U.S. Employees. The plan states that a participant is eligible for short term disability benefits if an illness, whether occupational or non-occupational, prevents them from performing the essential duties required for the job. In addition, the plan states that the participant would need to provide verification from a health care practitioner proving, that due to the disability, they will not be able to perform such duties. The plan requires, for both Short Term and Long Term Disability Plans, that the participants provide objective findings of disability. That is findings that their health practitioners observe through objective means, not the participants own description of the symptoms.

DI Law Group Successfully Resolves Cardiac Claim against Disability Insurance Co.

When our client, an attorney, originally hired us to help his with his ERISA long-term disability insurance claim, his claim for disability benefits had already been denied. He had been diagnosed with a cardiac condition and advised by his cardiologist to reduce stress and change his lifestyle in order to prevent further heart damage and possible heart failure. In keeping with his doctor's orders, he took on a less strenuous legal role in the law firm where he worked and significantly reduced his hours. After the filing of an appeal and then a lawsuit, the denial was ultimately reversed and our client continued to work in the reduced capacity prescribed by his physician and the insurance company paid his benefits for many years.

The Eleventh Circuit Overturns a Grant of Summary Judgment to United of Omaha in an ERISA Long-Term Disability Claim, Determining That Muscle Spasms and Back Pain Are Not Pre-Existing Conditions.

In a recent case, Horneland v. United Of Omaha Insurance Company,
No. 16-16935, __F.App'x__, 2017 WL 5508496 (11th Cir. Nov. 17, 2017), the Eleventh Circuit Court of Appeals reversed a federal district court's grant of summary judgment to United of Omaha ("UOO") in an ERISA governed disability insurance claim. Approximately fourteen (14) years prior to becoming employed as a real estate manager for Thornton Real Estate, Kristian Horneland fractured his thoracic spine in a slip and fall accident. With rehabilitation and pain management, following the accident Kristian was able to live a largely pain free existence. After becoming employed at Thornton Real Estate, Kristian became covered under a long-term disability policy with UOO which excluded Pre-Existing Conditions that manifest within a certain period of time and defined this as:

Hartford Will Purchase Aetna's U.S. Group Life and Disability Business for $1.45 Billion Cash

Hartford Financial Services Group just announced that it will purchase Aetna Inc.'s U.S. group life and disability business for $1.45 billion cash. Reuters reports that Hartford will use $273 million it has outstanding from its 2017 equity buyback program for the transaction, as well as dividends. It will not issue debt or equity for the purchase. "Hartford is financing the deal by dividends and clearly mentioned that it will not authorize an equity repurchase plan for 2018, driving the shares down," Atlantic Equities analyst John Heagerty said. The transaction will make Hartford the second-largest provider of group life and disability insurance in America with more than 20 million customers. It will also give Hartford access to Aetna's digital assets to improve its workers' compensation and disability claims processes. The assets include an integrated absence management platform.

Aetna is Ordered to Provide Discovery Pertaining to All the Facts Available to It at the Time it Denied Disability Benefits, Regarding its Financial Conflict of Interest, and Its Claims Representative's Communications with Aetna's In-House Counsel

In a recent case out of the Southern District of Florida, Johnston v. Aetna Life Ins. Co., No. 1720996 2017 WL 4654431 (S.D. Fla. Oct. 16, 2017), the court rejected Aetna's argument that discovery was not permitted, beyond the administrative record assembled and proffered by an insurer carrier in claims governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). The case involved a disability insurance claim filed by Dr. Roy Neil Johnson under his ERISA governed Aetna policy.

Aetna is Ordered to Provide Discovery Pertaining to All the Facts Available to It at the Time it Denied Disability Benefits, Regarding its Financial Conflict of Interest, and Its Claims Representative's Communications with Aetna's In-House Counsel

In a recent case out of the Southern District of Florida, Johnston v. Aetna Life Ins. Co., No. 1720996 2017 WL 4654431 (S.D. Fla. Oct. 16, 2017), the court rejected Aetna's argument that discovery was not permitted, beyond the administrative record assembled and proffered by an insurer carrier in claims governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). The case involved a disability insurance claim filed by Dr. Roy Neil Johnson under his ERISA governed Aetna policy.

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