For more than twenty-five years, the law of the Fifth Circuit has been that health and disability benefit denials based on factual determinations (e.g., whether a beneficiary is disabled or whether a treatment is medically necessary within the meaning of a plan) are reviewed by courts under an abuse of discretion standard, regardless of whether … Continue Reading
In Geiger v. Aetna Life Ins. Co., 845 F.3d 357 (7th Cir. 2017), Aetna initially determined that plaintiff qualified for disability benefits due to bilateral avascular necrosis in her ankles, which prevented walking and driving. When the definition of disability was about to change, Aetna conducted an Independent Medical Exam, which found her capable of … Continue Reading
The Second Circuit Court of Appeals recently held that claim fiduciaries must strictly comply with ERISA claim regulations or lose the deferential standard of review, as we have discussed in previous posts: Second Circuit rejects “substantial compliance” rule, Insurer’s Failure to Establish “Special Circumstances” for Extension of Time to Decide LTD Appeal Warrants De Novo Review, and … Continue Reading
Following the 2016 decision of the Second Circuit Court of Appeals in Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016), in which the Second Circuit rejected the doctrine of “substantial compliance” with ERISA claim regulations in favor of a much stricter interpretation, courts within the Second Circuit have increasingly held insurers and … Continue Reading
In a recent decision from the Southern District of New York in a case concerning a dispute over the denial of long-term disability (LTD) benefits, a District Court judge held that the LTD insurer had failed to establish special circumstances warranting an extension of the time frame for deciding the claimant’s appeal during the administrative … Continue Reading
In Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016), the Second Circuit made a significant change to the impact of ERISA claim regulations on subsequent litigation, rejecting the rule that it is sufficient for claim administrators to substantially comply with the regulations. Instead, the court held that, unless there is strict compliance … Continue Reading
In Burrell v. Prudential Ins. Co. of America, — F.3d –, 2016 WL 1426092 (5th Cir. Apr. 11, 2016), plaintiff argued that the plan did not give discretionary authority to Prudential, because the plan merely defined “Claim Fiduciary” as the person or entity “designated in the Plan (including the Summary Plan Description, Insurance Contracts or … Continue Reading
Shaw v. AT&T Umbrella Ben. Plan No. 1, 795 F.3d 538 (6th Cir. 2015) concerned denial of plaintiff’s claim for disability due to chronic neck pain. The district court affirmed the denial, but the 6th Circuit reversed, finding the determination arbitrary and capricious. The court took issue with much of the claim administration, criticizing the … Continue Reading
Roganti v. Met. Life Ins. Co., 786 F.3d 201 (2d Cir. 2015), involved a dispute over the effect an arbitral award for improper employment practices had on pension benefits. The opinion is useful for generalizing into the pension context many of the rules underpinning the arbitrary and capricious standard of review as applied to benefit … Continue Reading
In Becker v. Williams, — F.3d –, 2015 WL 348872 (9th Cir. Jan. 28, 2015), the plan participant called the plan administrator to change the beneficiary of his pension plans from his ex-wife to his son. His employer sent him beneficiary change forms, but he never completed them in the years before he died. After … Continue Reading
In Brake v. Hutchinson Tech. Inc. Grp. Disability Income Ins. Plan, 774 F.3d 1193 (8th Cir. 2014), the court determined that, where a policy insuring a South Dakota resident was issued in Minnesota to a Minnesota employer, and provided that it was governed by Minnesota law, then a South Dakota regulation precluding discretionary clauses could … Continue Reading
In Johnson v. United of Omaha Life Ins. Co., 775 F.3d 983 (8th Cir. 2014), the court determined that the district court erroneously reviewed the administrator’s determination under the de novo standard, instead of the arbitrary and capricious standard. It ruled that it did not need to decide whether procedural irregularities still could result in … Continue Reading
In Rice v. ReliaStar Life Ins. Co., 770 F.3d 1122 (5th Cir. 2014), the police responded to a 911 call about the decedent, Rice, sitting in his car, in his garage, with a gun to his head, threatening suicide. After various failed efforts by the police to get him to surrender, he walked toward the … Continue Reading
In George v. Reliance Standard Life Ins. Co., 776 F.3d 349 (5th Cir. 2015), a case of first impression, a divided Fifth Circuit panel decided when a disability is “caused by or contributed to by” a mental illness. The plaintiff was a helicopter pilot who was disabled due to pain suffered at the site of … Continue Reading
In Butler v. United Healthcare of Tennessee, Inc., — F.3d –, 2014 WL 4116478 (6th Cir. Aug. 22, 2014), the court addressed what appeared to be a relatively straightforward health care benefit question, complicated by what the court described as a severely recalcitrant claim administrator.… Continue Reading
In Hall v. Met. Life Ins. Co., 750 F/3d 995 (8th Cir. 2014), the plaintiff’s husband participated in a life insurance plan, in which he named his son as beneficiary. After he married plaintiff, he executed a change of beneficiary form, but it was not filed until after he died. Shortly before his death, he … Continue Reading
In Waldoch v. Medtronic, Inc., 757 F.3d 822 (8th Cir. 2014), the plaintiff argued that the plan’s grant of discretionary authority was overridden by procedural irregularities in plan administration, compelling use of the de novo standard of review. To counter that argument, Medtronic submitted an affidavit with supplemental evidence demonstrating its claims handling process. The … Continue Reading
Ingravallo v. Hartford Life & Acc. Ins. Co., 2014 WL 1622798 (2d Cir. Apr. 24, 2014), doesn’t break any new legal ground, but it is nonetheless noteworthy for several reasons. It is rare that the Circuit reverses a District Court’s determination; here, it reversed and directed entry of judgment for Hartford. Second, it contains excellent … Continue Reading
I imagine that, for a federal judge, getting reversed is not pleasant, even though it’s part of the job. Well, pity poor Judge Larimer of the Western District of New York, who has now been reversed three times in the same case – twice by the Second Circuit and once by the Supreme Court.… Continue Reading
Every so often a bit of legal synchronicity seems to occur. Sometimes its personal, like when you have several cases with the same uncommon issue, or multiple cases in the same rarely visited court. In 2013, there appears to be a larger force at work that has caused three circuits to address the question whether … Continue Reading
The tough disability claims are often the ones where it is difficult or impossible to prove the medical condition with objective evidence (something that can be observed or measured). This requires the plan fiduciary to decide whether the subjective evidence is adequate. A recent decision, which found the fiduciary got it wrong, provides helpful guidance … Continue Reading
In 2011, the Supreme Court clearly held that a summary plan description cannot trump the terms of an ERISA plan, overturning the rule in many circuits. Instead, the Amara rule provides that the plan itself governs over a summary of the plan when the two conflict. This does not mean that an SPD is meaningless. … Continue Reading
Revenue sharing is an arrangement under which a mutual fund in which pension assets are invested pays a portion of its fees to the entity that services the pension plan. In Leimkuehler v. American United Life Ins. Co., 713 F.3d 905 (7th Cir. 2013), the Seventh Circuit held that the arrangement did not violate ERISA … Continue Reading
Often the most common divide between a participant claiming disability benefits and the claim administrator evaluating the claim is the weight to be given the opinion of a treating physician. Time was that a claimant argued that the administrator must defer to the treating physician, like the Social Security Administration does. That argument, at least … Continue Reading
