Archives: Plan Interpretation

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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

Sixth Circuit Explains Why SPD is Still Important After Amara

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

“Injured While Intoxicated” Means What It Says

Life insurance plans, accidental death and dismemberment plans, and disability plans often exclude coverage for losses that occur while the participant is intoxicated, or where the loss is intentionally self-inflicted. Though these exclusions are often very clear, they are often the subject of contentious disputes over what, exactly, they mean, or were intended to mean, … Continue Reading

Vesting of Employee Welfare Benefits – Who Knew It Was So Complicated?

One of the great things about writing this blog is learning something new. I sometimes fall into the trap of determining the law on a particular issue in the circuit in which I practice most (the Second), and assume that other circuits are the same. Sometimes, though, it turns out that one circuit is not … Continue Reading

Including Ambiguous Plan Language Verbatim In the SPD Can Effectively Eliminate Discretion to Interpret It — At Least in the Fifth Circuit

In Koehler v. Aetna Health, Inc., 683 F.3d 182 (5th Cir. 2012), the Fifth Circuit criticized a health insurer for having an SPD that mirrored the plan, and held that Cigna v. Amara did not prevent the terms of the SPD from impacting plan interpretation. The plaintiff, a participant in an HMO, suffered from sleep … Continue Reading

Social Security Statute Aids Interpretation of Ambiguous Plan Offset Provision

In Lipker v. AK Steel Corp., 2012 WL 5346325 (6th Cir. Oct. 31, 2012), the plaintiff applied for surviving spouse benefits under the pension benefits plan administered by her husband’s former employer. The administrator approved her claim, but she disputed the amount of the benefit. The discrepancy between her expectation and the actual award hinged … Continue Reading
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