Claim Denial Letters

News & Analysis as of

Not all Plans can Establish a Shortened Limitations Period for Filing Lawsuit

I recently blogged about a case in which a plan had established a shorter period of time (one year deadline) for filing a lawsuit, rather than relying on the state statute of limitation (six years) which would otherwise have...more

The ERISA Litigation Newsletter - September 2015

Editor's Overview - It has been a little more than one year since the U.S. Supreme Court altered the legal landscape for litigating ERISA breach of fiduciary duty claims relating to the investment in employer stock...more

Don’t Play Hide the Ball with Your Claims Procedure

ERISA does not have a statute of limitations for lawsuits brought by participants to check claim benefits under the plan. Instead, courts borrow from similar state statutes of limitations. In a decision two years ago, the US...more

Court of Appeals to Plan Administrators: Inform Claimants of Time Limits on Front End of Discussions

Recently, in Mirza v. Insurance Administrator of Am., Inc., __ F.3d__ (3d. Cir. 2015), the United States Court of Appeals for the Third Circuit was asked to determine whether plan administrators are required to include a...more

New Restrictions: CMS Limits Scope of Review on Redeterminations and Reconsiderations for Certain Audit Appeals

On August 13, 2015, the Centers for Medicare & Medicaid Services (CMS) issued instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for...more

Third Circuit – Failure to Identify Plan’s Limitation Period in Denial Letter Precludes Enforcing Deadline

In 2013, the Supreme Court reaffirmed that ERISA plans can impose shorter limitations periods than would otherwise be the case if the plan was silent. Nevertheless, the United States Court of Appeals for the Third Circuit...more

ERISA: 3rd Circuit — Denial Letters That Fail to Detail Plan’s Limitation Period Are Invalid

The courts are expecting more detail in your denial letters about the limitations period. Here’s the case of Mirza v. Insurance Administrator of America, Inc.., No. 13-3535 (3rd Cir. August 26, 2015)(“One very simple...more

Third Circuit Rules Failure to Disclose Deadline to File Suit in Denial Letter Warrants Setting Aside Limitations of Suit...

The Third Circuit ruled on August 26, 2015, that if a claim administrator fails to disclose in its final denial letter any plan-imposed deadline to challenge the denial in court, then that deadline will be set aside in favor...more

Third Circuit Says ERISA Administrative Appeal Denial Letters Must State Plan-Imposed Time Limits

The Third Circuit recently held that ERISA administrative appeal denial letters must include plan-imposed time limits for commencing a lawsuit challenging the claim denial, and the failure to provide such notice warranted...more

Bad Faith Sentinel - July 2015

Eighth Circuit: No Bad Faith Where Insured Failed to Make a Sufficient Demand and Insurer Refused to Entertain Settlement Offer Prior to Completing Investigation - Purscell v. Tico Ins. Co., No. 13-2362, 2015 WL 3855253...more

New Jersey Judge Writes a Primer on How Not to Draft a Denial Letter

Last month, a federal trial court in New Jersey shot down an insurer’s arguments that it had unambiguously denied coverage for Superstorm Sandy damage in a letter to the insured. In Liguori v. Certain Underwriters at Lloyds,...more

Employee Benefits Developments - July 2015

Second Circuit Holds That Posthumous QDROs Are Valid. Yale-New Haven Hospital brought an action in federal court to resolve competing claims by a former spouse of a deceased participant and the deceased participant’s...more

ERISA 11th Circuit: Claimant Has “Duty to Investigate” When Asserting Equitable Tolling of a Contractual Limitations Provision

You already know that contractual limitations provisions in ERISA plans are generally enforceable and can bar untimely claims. But when does the court apply “equitable tolling” to extend the time by which a claimant may...more

Middle District of Pennsylvania: No Bad Faith Where Insurer’s Brief Inspection Yielded Reasonable Basis to Deny Claim

Boulware v. Liberty Ins. Corp., No. 3:13-CV-1541, 2015 WL 1219283 (M.D. Pa. Mar. 17, 2015). After a portion of the insured’s deck collapsed, the insurer denied coverage based on a brief inspection without hiring an...more

Insuring Your Business - December 2013: Insurance Coverage for Food Claims: Communicating with Your Insurance Company

One of the most frustrating aspects of dealing with a food insurance claim can be communicating with your insurance company adjuster. Knowing your insurance company’s obligations to you can help reduce the frustration....more

SEC Further Limits Ability of Companies to Settle on a "No Admit, No Deny" Basis

The Securities and Exchange Commission (SEC) recently further limited the ability of companies to settle claims without admitting to the SEC’s charges. Traditionally, the SEC had allowed defendants to settle enforcement...more

Understanding The Social Security Disability Appeals Process

Our firm is focused on relieving the hardship experienced by our clients either through experienced representation in personal injury matters or by helping you apply for needed workers’ compensation or Social Security...more

Seventh Circuit Confirms Viability of Claims Made Defense in Errors and Omissions Policy Dispute

The Seventh Circuit confirmed that the notice requirements of “claims-made” policies entitle insurers to deny coverage where, before the policy’s inception, the insured knows of circumstances that “might reasonably be...more

Why Nothing is Happening on Your Claim

Most injured workers who call my office are fed up with delays in getting decent medical care or getting compensation checks from the workers' compensation adjuster. Here's a list of why you might be having problems...more

It Pays To Add A Statute Of Limitations To Your Plan’s Claims Procedure

ERISA requires that plans contain a reasonable claims procedure. Courts have generally required claimants to exhaust that claims procedure before filing a lawsuit. In addition, if the plan gives the plan administrator...more

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