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May 2017 Archives

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.

Bert Bell/Pete Rozelle NFL Player Retirement Plan and the NFL Player Supplemental Disability Plan Ordered by Federal District Court to Pay NFL Player Full Disability Benefits

The Bert Bell/Pete Rozelle NFL Player Retirement Plan and NFL Disability Plans are notoriously difficult for a NFL player to collect benefits under from the NFL. Further discouraging is that rarely are the cases filed by NFL players denied disability benefits under these Plans won in court. However, recently, a federal district court found that the Bert Bell/Pete Rozelle NFL Player Retirement Plan and the NFL Player Supplemental Disability Plan were wrong to deny disability benefits to retired player Jesse Solomon and ordered the NFL Plans to pay him the full disability benefits at issue.


Long Term Care/Home Health Care Insurance providers seem to make a habit of doing everything possible to delay making a decision on a long term or home health care claim for benefits in what would appear to be a clear effort to avoid paying benefits owed under these very important, and often lifesaving policies. Like many of our clients, Mrs. X procured an insurance policy that would pay for a health care aid in her home if and when she needed assistance with at least two of the Activities of Daily Living. At age 91, she had balance issues and was weak; and thus it became dangerous for her to bathe without hands on assistance, get dressed without hands on assistance, and get in and out of chairs, her bed, or a car without either hands on or standby assistance. Despite what would appear to be her clear right to benefits under her policy, her long term care insurance company, John Hancock, continued to request information from Mrs. X and her physicians, claiming they did not have sufficient information upon which to make a decision. Because Mrs. X could not function without assistance from an aide and had little family in the area that could help her, she was forced to pay the home healthcare aid from her own limited finances, thereby making it extremely difficult for her to meet her monthly financial obligations.

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