Archives: Plan Interpretation

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Second Circuit Clarifies New York Anti-Subrogation Law Prohibits Offsets For Settlements; Declares Plan’s Choice-of-Law Provisions May Not Govern Offset And Subrogation Rights

The U.S. Court of Appeals for the Second Circuit has ruled that New York’s anti-subrogation statute, N.Y. Gen. Oblig. Law § 5-335(a), applies both to “offsets” for prospective benefit payments and to reimbursements for prior benefit disbursements.  In so holding, the Second Circuit ruled that a Plan’s choice-of-law provisions may not be dispositive of which … Continue Reading

Unpaid employer contributions cannot be plan assets; debt is dischargeable in bankruptcy

Bos v. Bd. of Trustees, 795 F.3d 1006 (9th Cir. 2015), involved the owner of a company that participated in a multi-employer pension plan. Because the owner had full control over the company finances, he was personally responsible for making the required contributions. Moreover, he signed a promissory note for some $360,000 in payments that … Continue Reading

SPD can be governing plan document when there is no actual plan

Bd. of Trustees v. Moore, 800 F.3d 214 (6th Cir. 2015), considered whether a summary plan description (SPD) that was the only document containing a subrogation provision was a binding plan document. The Board of Trustees of the National Elevator Industry (NEI Board) established a health benefits plan, pursuant to two relevant documents. The first … Continue Reading

Death Resulting From DVT Caused By Long Flights Not Covered Under AD&D Policy

Williams v. Natl. Union Fire Ins. Co. of Pitt., 2015 WL 4080909 (9th Cir. July 7, 2015) involved the death of “an acclaimed horticulturist” from pulmonary embolism triggered by deep vein thrombosis after flying approximately 28 hours over five days. Plaintiff was covered by an AD&D policy through his employer. The policy covered death as … Continue Reading

State Law Is Not A “Controlling Statute” Overriding Contractual Limitation

Heimeshoff v. Hartford Life & Acc. Ins. Co., 134 S. Ct. 529 (2013), held that a contractual limitation period in an ERISA plan is enforceable as written unless the period is unreasonably short, or a “controlling statute prevents the limitations provisions from taking effect.” In Heimeshoff, there was no dispute that the contractual limitation provision … Continue Reading

Sixth Circuit At it Again: Orders Make-Whole Relief in Disability Benefit Claim

In Stiso v. Intl. Steel Group, 2015 WL 3555917 (6th Cir. June 9, 2015), the court reversed a ruling by the district court that dismissed a claim for make-whole relief, and directed the district court “to grant an equitable remedy [against the employer and insurer] equivalent to the promised increase in benefits to plaintiff.” The … Continue Reading

Beneficiary Designation Forms Are not Plan Documents; Change of Beneficiary By Phone Was Sufficient

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

Eighth Circuit Enforces Choice of Law Clause; Discusses Test for Evaluating Reasonableness of Plan In-terpretation

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

Insurer Reasonably Denied AD&D Claim Following “Suicide By Cop”

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

Court Provides Narrow Interpretation for Mental Illness Limitation

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

Ninth Circuit Discusses Limits On Make-Whole Equitable Remedies for Breach of Fiduciary Duty

In Gabriel v. Alaska Electrical Pension Fund, 755 F.3d 647 (9th Cir. 2014), a venal claimant met a not-very competent plan administrator, and the result was a helpful discussion of limits on make-whole equitable claims. [Note, on December 16, 2014, the Ninth Circuit panel withdrew this opinion, and replaced it with a new one, at … Continue Reading

Administrator is Entitled to Require Strict Compliance With Plan Procedures

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

Evidence Outside of Administrative Record Is Admissible to Determine Standard of Review

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

Sixth Circuit Adopts “Clear-Notice” Rule Before Statutory Penalties Can Be Imposed

Cultrona v. Nationwide Life Ins. Co., 748 F.3d 698 (6th Cir. 2014), involved the denial of benefits under an accidental death policy on the ground that the plaintiff’s husband’s death was excluded due to his intoxication. The court found that determination to be reasonable. But the court also affirmed the district court’s determination that the … Continue Reading

Must disability claim administrators now obtain the SSDI file in the 11th Circuit?

A divided panel on the Eleventh Circuit has imposed on plan administrators “an obligation to consider the evidence presented to the SSA” by the claimant. While it is not particularly novel to hold that an SSDI award must be considered – most circuits require disability claim administrators to consider an SSDI award, or at least … Continue Reading

Frommert v. Conkright: The Saga Continues, or “Strike Two for Xerox”

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

Heimeshoff v. Hartford Life: Supreme Court Holds that Plan Can Start Limitation Clock Before Benefit Claim Accrues

In Heimeshoff v. Hartford Life & Acc. Ins. Co., 571 U.S. __ (Dec. 16, 2013) , the Supreme Court held that a contractual limitation provision under which the clock begins to run before administrative remedies are exhausted  is enforceable under ERISA, as long as a reasonable time is left after exhaustion is expected to occur. … Continue Reading

Effect of Requiring “Satisfactory” Proof Is A Popular Issue in the Circuits This Year

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

Heimeshoff v. Hartford – Supreme Court Briefing

In petitioning for certiorari, Heimeshoff asked the Supreme Court to consider three questions: 1.         When should a statute of limitations accrue for judicial review of an ERISA disability adverse benefit determination? 2.         What notice regarding time limits for judicial review of an adverse benefit determination should an ERISA plan or its fiduciary give the claimant … Continue Reading

Hartford v. Heimeshoff – ERISA Regulations and Equitable Tolling

At the District Court, Heimeshoff also argued that the limitation period in the plan should be equitably tolled because, she claimed the applicable ERISA regulation required Hartford to disclose the limitation period in its denial letter, and it failed to do so. Hartford argued that it was irrelevant whether the regulation required disclosure because Heimeshoff … Continue Reading

Heimeshoff v. Hartford – Motion to Dismiss

Hartford moved to dismiss the action because it was filed after the expiration of the policy’s contractual limitation period. The plain language of the Policy gave her until December 8, 2005 to submit proof of loss: she alleged that her disability began on June 6, 2005; the ninety-day Elimination Period would ordinarily end on September … Continue Reading
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