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ERISA Archives

Federal District Court Finds that Hartford Failed to Provide a Claimant with a Full and Fair Review of her ERISA Governed Disability Insurance Claim.

In a recent case out of the Southern District of Indiana, Miller v. The Hartford Life And Accident Insurance Co., & Springleaf Finance, Inc. Disability Plan, No. 116CV00166TWPDML, 2017 WL 2214938 (S.D. Ind. May 19, 2017), the federal court found that Hartford failed to afford the Plaintiff a full and fair review of her ERISA governed disability insurance claim and remanded the matter back to Hartford to reevaluate the claim.

Reliance Standard Life Insurance Company Denial Tactics Dismissed By Court in ERISA Disability Case

Most individuals who have filed any type of insurance related claim have experienced the delay and denial tactics used by their insurance company to avoid payment. Disability carriers often take extreme and arguably egregious measures to "prove" that a claimant is not disabled under the terms of their disability policy. In a recent case, the US District Court for the Northern District of California found Reliance Standard Life Insurance Company's (RSL) denial of benefits wrong and ordered the company to reinstate the Plaintiff's benefits.

Seventh Circuit Upholds District Court's Decision that a Claimant with Fibromyalgia was Disabled under her ERISA Governed Disability Plan and Commented on the Disabling Nature of Fibromyalgia.

In a recent case, Kennedy v. The Lilly Extended Disability Plan, No. 16-2314, __F.3d__, 2017 WL 2178091 (7th Cir. May 18, 2017), the Seventh Circuit Court, overturned a disability insurance benefit denial of a claimant with fibromyalgia. The claimant in the Kennedy case was the executive director of Lilly's human resources department, earning a monthly salary of $25,011. Kennedy was diagnosed with fibromyalgia and was suffering from its severe symptoms. Ultimately, she was unable to continue to work and filed a claim for disability benefits under Lilly's self-funded ERISA governed disability plan. Originally, Kennedy's claim was approved and she received benefits for over three years. However, the plan required Kennedy to undergo a physical evaluation over 100 miles from her home by a physician it hired. The "examination" lasted a mere five-minutes. The plan also hired a rheumatologist to conduct a records review of Kennedy's medical information, who falsely alleged that the American
College of Rheumatology does not consider fibromyalgia to be disabling on an extended basis. Based on the opinions of these two physicians, the plan terminated Kennedy's benefits.

The Fifth Circuit Court of Appeals Calls into Question Whether Deference Should be Given to the Factual Benefit Determinations of ERISA Plan Administrators.

In a recent decision, Ariana M v. Humana Health Plan of Texas, Inc., 2017 WL 1423765 (5th Cir. April 21, 2017), the Fifth Circuit Court of Appeals called into question the validity of its holding in Pierre v. Connecticut General Life Insurance Co./Life Insurance Co. of North America, 932 F.2d 1552 (5th Cir. 1991), in which the Fifth Circuit held that courts had to give deference to an ERISA benefit plan administrator's factual determinations, even if the plan did not contain a discretionary clause. Accordingly, under Pierre, a reviewing court cannot overturn an ERISA plan administrator's denial of benefits unless it found that the denial of benefits was arbitrary and capricious, an extremely high bar to reach for claimants.

Court Overturns Northwestern Mutual's Denial of Disability Insurance Benefits to Attorney With Congestive Heart Failure Unable to Handle Stress

A federal district court recently overturned Northwestern Mutual's denial of own occupation disability insurance benefits to an attorney with congestive heart failure unable to handle stress. The case Mustain-Wood v. Northwestern Mututal Life Insurance Company involved a family law attorney and partner at his own law firm who experienced congestive heart failure requiring major surgery and cardiac rehabilitation. 938 F.Supp. 2d 1081 (D. Co. 2013). Mustain-Wood became unable to practice as an attorney in part because of the high stress environment it required.

The things the insurance company may not tell claimants about their rights under ERISA

There are many things that an administrator or insurance company may not tell claimants about their rights in ERISA benefit claims and ERISA appeals (when there has been a denial of their ERISA benefits). Just a few of the many things that the insurance company may not reveal to claimants about their ERISA rights includes:

Do You Have the Right Information to Be Successful in Your Application for Benefits Under or Appealing a Denial of Your ERISA Disability Insurance Claim?

Most group policies that you obtain as a result of your employment are governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). ERISA is a federal statute that provides extremely strict deadlines and guidelines for claimants and insurance companies to abide by in the processing of a claim, submission of an appeal, and ultimately the determination of eligibility for benefits under a disability insurance policy. Most significant, ERISA creates an unequal claims process, placing strict obligations on individuals pursuing benefits that make maneuvering a claim difficult and frustrating for unaware claimants at a time when they should be focusing on their recovery. If you are applying for benefits or have been denied benefits under an ERISA governed Plan, you should be aware of your obligations in proving your claim and the strict deadlines you are working under.  The question is, do you have the right information to be successful when applying for benefits under or appealing a denial of your disability insurance claim? 

Supreme Court will Review an Insurance Carrier's Right to Reimbursement under ERISA

On June 25, 2012, the United States Supreme Court granted certiorari review in the case US Airways, Inc. v. McCutchen, which will greatly impact the landscape of employee benefits law, which is largely governed by the Employee Retirement Income Security Act of 1974 ("ERISA").   In granting the writ of certiorari, the Supreme Court explained:

Is Your Insurance Benefits Claim Governed by ERISA?

ERISA stands for the Employee Retirement Income Security Act which was passed by Congress and signed into law by President Ford in 1974. When the Employee Retirement Income Security Act ("ERISA") became law, it was codified as a part of Title 29 of the United States Code, and is found in multiple sections beginning with Section 1001. Essentially, the Employee Retirement Income Security Act is a federal law that supersedes state laws and regulates employee benefit plans and determines the rights of beneficiaries under those plans. This includes disability, life, health or long-term care insurance benefits that are provided to employees as a benefit of their employment by employers. The statute defines an "employee welfare benefit plan" as "any plan, fund or program . . . established or maintained by an employer or by an employee organization" which provides employee benefits. An "employee welfare benefit plan" subject to the Employee Retirement Income Security Act is easily created by an employer when establishing a plan to provide group insurance benefits to its employees. In fact, insurance policies and benefits obtained through an employer typically fall under this law.

What is ERISA?

ERISA stands for the Employee Retirement Income Security Act which was passed by Congress in 1974 and signed into law by President Gerald Ford on Labor Day, September 2, 1974. When the Employee Retirement Income Security Act ("ERISA") became law, it was codified as a part of Title 29 of the United States Code, and is found in multiple sections beginning with Section 1001. There have been a number of important amendments to ERISA since its 1974 enactment, including the COBRA and HIPAA laws. Essentially, the Employee Retirement Income Security Act is a federal law that supersedes state laws and regulates employee benefit plans and determines the rights of beneficiaries under those plans. This includes disability, life, health or long-term care insurance benefits that are provided to employees as a benefit of their employment by employers. The statute defines what is considered to be an employee benefit plan governed by ERISA, who is an ERISA administrator responsible under ERISA for the employee benefit plan, and who is an ERISA participant (employee) and beneficiary covered under ERISA. One of the primary goals in the enactment of ERISA was to promote the interests of employees and their beneficiaries and to assure that employees received promised benefits from their employers - this was expressly written by Congress into the ERISA statute itself. In addition to ERISA setting minimum standards required for ERISA employee benefit plan creation and administration, it requires ERISA administrators to provide participants with certain plan information, it creates fiduciary responsibilities of the ERISA administrator to plan participants, requires ERISA plans to establish a grievance and appeals process for participants to obtain benefits under their plan, and gives participants the right to bring a lawsuit in federal court to pursue plan benefits and breaches of fiduciary duty by the ERISA administrator/plan. The regulations enacted by the United States Department of Labor pursuant to ERISA further provide for very specific strict deadlines, claims procedures, and internal structuring that the ERISA administrator (or insurance company) shall abide by and create to promote fairness and consistency in claim determinations involving ERISA benefits.

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