Claim Procedures

News & Analysis as of

DOL Tightens Disability Claim Processing Rules

“Isn’t this an ACA blog?” Yes, it is. “So, why are you writing about disability plan administration?” Because they said so. The preamble to the proposed rules explains – Inasmuch as disability and lost earnings can be sources...more

Natural Disasters in Latin America: Reinsurance Issues

According to initial reports, Hurricane Patricia didn't end up causing nearly the damage that the world’s most powerful hurricane could have caused. It is a good reminder, however, for reinsurers of how sudden and...more

Seventh Circuit Reverses Injunctive Relief for Chiropractic Association

On October 1, 2015, the United States Court of Appeals for the Seventh Circuit reversed what was previously regarded as a victory for the Pennsylvania Chiropractic Association. The case, Pennsylvania Chiropractic Association...more

Project In(Site): Legal Developments Impacting Construction & Government Contract Industries

Welcome to the inaugural issue of Project In(Site), Seyfarth’s Construction and Government Contracts practice groups’ publication focusing on decisions or other items of interest for construction and government contract...more

Catching Up To Insurers’ Use of Big Data

Various groups within the NAIC are beginning to study the way in which insurers are using big data. On the property and casualty front, the Market Regulation (D) (Market Reg) Committee is reviewing the use of big data in...more

The CHRO Complaint Process Needs A Reboot

Lately, I’ve been hearing a lot of complaints about the Connecticut Commission on Human Rights & Opportunities from both attorneys and clients. And I’ve come to one conclusion: The CHRO Complaint Procedure needs a...more

ERISA: When Does A Claimant Get To “Augment” The Administrative Record?

You already know that judicial review of ERISA claims generally will be limited to the administrative record considered by the claim administrator. But the courts will allow claimants to augment the record if ERISA...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

HUD’s Proposal to Terminate FHA Insurance Policies Could Terminate the FHA Program

If there is anything that galls servicers of government-insured loans, it is the forfeiture or curtailment of all accrued interest from mortgage insurance claims resulting from the failure to foreclose fast enough within...more

A Primer on Insurance Underwriting in China

China is one of the largest and fastest-growing insurance markets in the world. It provides the global insurance and reinsurance industry with tremendous opportunities but also presents challenges with its unique legal and...more

Seeing the Finish Line: Courts Increasingly Exempt Claims-Made Policies from the Notice Prejudice Rule

In a majority of jurisdictions, the “notice-prejudice rule” provides that an insurer may not deny a claim on grounds of late notice without demonstrating prejudice. The rule is statutory in some states and judicially crafted...more

Bad Faith Sentinel - April 2015

In This Issue: - En Banc Mississippi Court of Appeals Affirms Summary Judgment for Insurer, Adjuster and Employer on Bad Faith Claims Arising from Denial of Coverage and Benefits for Work-Related Injury -...more

Cooperate, Or Else

Cooperation is key. Or so says the 10th Circuit at least, in addressing an appeal from a district court’s dismissal of an insured’s action in which he failed to cooperate with his insurer’s claim investigation. The 10th...more

Claims Administration and Handling in Mass Tort Cases: Lessons from Deepwater Horizon

In mass casualty and toxic tort litigation, an effective means of providing prompt and efficient compensation to victims can benefit all stakeholders. Claimants receive prompt payment for lost property or business expenses,...more

2014 Hail-Related Insurance Litigation Year In Review

The number of lawsuits arising from hail-damage claims to residential and commercial properties has increased dramatically over the past few years. Indeed, since 2012, hundreds of lawsuits alleging underpayment of...more

Procedural Errors Don’t Alter Standard of Review In ERISA Claim for Benefits

The Ninth Circuit recently held that where an ERISA plan provides the plan administrator discretionary authority to determine benefit claims, procedural violations that occur during the course of the administrative claims...more

DOL’s New Audit Focus? Health Plan Claims and Appeals and Hard to Value Assets

In recent talks and appearances, representatives of the U.S. Department of Labor have issued a warning about new areas of focus of DOL audits and enforcement actions. While there are a number of different enforcement...more

Statute of Limitations for Submitting a Claim Against CIGA

Statute of Limitations for Submitting a Claim Against CIGA - Court Of Appeal, First Appellate District (September 17, 2014) - The California Insurance Guarantee Association (“CIGA”) has a statutory duty to pay...more

Insurer Sues Department of Insurance Over Multi-Million Dollar Penalty

In suing the California Insurance Commissioner on July 10, 2014, PacifiCare Life Insurance Company sought a writ of mandamus ordering the Commissioner to set aside his Decision and Order imposing a record $173 million penalty...more

CMS Waves Partial White Flag in Appeals of Payment Status Denials

For the last several years, hospitals, on the one hand, and the Centers for Medicare and Medicaid Services and its contractors (collectively, CMS), on the other, have been engaged in a spirited dispute over claims denials for...more

Start Spreading the News: With National Union v. TransCanada, New York Prepares to Broadcast Communications with Coverage...

The final opinion of a New York appellate court in National Union Fire Ins. Co. of Pittsburgh v. TransCanada Energy USA, Inc., 119 A.D.3d 492 (2014), is only three paragraphs long, but it raises a host of questions about how,...more

New Jersey Court Holds that Six-Month Delay in Providing Notice to Carrier Bars Coverage under Claims-Made Policy

Policyholders often are cautioned to provide notice of a claim to their insurance carrier as soon as possible to avoid the risk that the carrier will deny coverage due to late notice. A recent court decision in New Jersey...more

It is Always Good to Follow the Plan’s Claims Procedure in Denying a Claim – Part 2

Some months ago I blogged about an Eighth Circuit Court of Appeals decision involving high ranking executives participating in a company’s long term incentive plan where the executives won their suit under the plan, at least...more

Arizona’s Notice Of Claim Statute – Jumping Through Hoops When Suing State Government Or Its Agencies Or Political Subdivisions

For 20 years, the State of Arizona, its agencies and political subdivisions have held a secret weapon to thwart claims made against them for everything from breach of employment contracts to gross negligence in providing...more

Petiioner Can Submit Supplemental Information Challenging Additional Claims

In Callidus Software Inc. v. Versata Software, Inc., CBM2013-00052, Paper 26, CBM2013-00053, Paper 21, CBM2013-00054, Paper 24 (March 28, 2014), Petitioner sought to file supplemental information to challenge dependent claims...more

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