Denial of Benefits

News & Analysis as of

Sixth Circuit Rejects Claim that Disgorgement of Profits Is Appropriate Remedy in ERISA Benefit Denial Action

On March 5, 2015, the U.S. Court of Appeals for the Sixth Circuit, sitting en banc in the matter of Rochow v. Life Insurance Company of North America, 2015 WL 925794 (6th Cir. Mar. 5, 2015), reversed the finding of a prior...more

ERISA: 6th Circuit — Plop Plop, Fizz Fizz: Oh What A RELIEF It Is: No Disgorgement For Arbitrary Denial Of Benefits

Does an arbitrary and capricious denial of ERISA governed disability benefits create a right to disgorgement of profits? NO....more

Revisiting Rochow: The Sixth Circuit Rejects Earlier $3.8 Million Equitable Award in Recent En Banc Decision

Just over a year ago, a panel decision by the Sixth Circuit Court of Appeals in Rochow v. Life Insurance Company of North America, 737 F.3d 415 made big news when the court upheld the district court’s award of $3.8 million in...more

Sixth Circuit Overturns the Lower Court’s Award of $3.8 Million in Alleged Profits Arising From a Denial of Benefits

The U. S. Court of Appeals for the Sixth Circuit, sitting en banc, has overturned the decision of a divided three-judge Sixth Circuit panel which had affirmed the district court’s award of $3.8 million of “disgorged” profits,...more

ERISA (11th Cir.): Claim Barred by Statute of Limitations Even When Administrator Cannot Produce Denial Letter

What happens when a claim denial letter was issued, but the claimant denies ever receiving it, and the administrator can’t produce it? How does that affect the statute of limitations? ...more

Judge in NY County Supreme Court encourages insured to appeal her decision, following Mighty Midgets case, ruling that insured is...

In a highly unusual decision, Judge Shirley Kornreich in Madison 96th Associates v. 17th East Owners Corporation, 43 Misc.3d 1210(A), denied an attorney-fee award to a prevailing plaintiff-insured in a declaratory judgment...more

Fourth Circuit: Twenty-Seven Days of Inaction Enough to Waive Right to Rescind for Violations of Protective Safeguards Clause

The marriage liturgy in the Anglican Book of Common Prayer contains the well-known line “speak now or forever hold your peace,” and the take-away from a recent Fourth Circuit decision out of North Carolina is clearly “act now...more

Legal Alert: It’s Time to Review Benefit Denial Letters

On August 7, the U.S. Court of Appeals for the Sixth Circuit decided in Moyer that the contractual time limits governing the period during which a participant must initiate judicial review of a benefits denial must be...more

Bad Faith Sentinel - August 2014

In This Issue: - Northern District of Texas Dismisses Bad Faith Claims in Well-Control Policy Dispute - District of South Dakota: Denying a Claim for Reasons Known to be False is Not a Reasonable Basis to Deny...more

Northern District of Ohio: No Reasonable Jury Could Conclude That Insurer’s Denial of Coverage For Two Arsons Was Not Justified

Givens v. West Bend Mut. Ins. Co., No. 4:13 CV 1287, 2014 WL 2946672 (N.D. Ohio Jul. 1, 2014) - The Northern District of Ohio concludes that insurer was justified in denying claim for two fires that were undisputedly...more

District of South Dakota: Denying a Claim for Reasons Known to be False is Not a Reasonable Basis to Deny a Claim

Lewison v. W. Nat’l Mut. Ins. Co., Civ. No. 13-4031-KES, 2014 WL 3573403 (D.S.D. July 21, 2014). The District of South Dakota grants in part and denies in part an insurer’s motion for summary judgment on two...more

New York’s High Court Holds That An Insurer’s Delay in Disclaiming Coverage Could Be Excused When The Delay Resulted From...

Until recently, New York’s Insurance Law presented something of a dilemma for insurance companies concerning how quickly they were required to inform their policyholders that they were denying coverage for a claim. On the one...more

ERISA: 6th Circuit — Benefit Denial Letters: Include The Time Limit For Judicial Review Or Lose Contractual Limitations Defense

Does your ERISA claim benefit denial letter preserve the contractual limitations defense? If your denial letter fails to expressly state the contractual limitations timeframe, it might not preserve that defense. ...more

Mediation of Insurance Coverage Cases

Resolving insurance coverage disputes through mediation requires careful assessment of three unique elements: the insurance policy, the rules applicable to the application of the policy and the cases construing the policy....more

Eleventh Circuit Dials Back The Specificity Required In An Insurer’s Reservation of Rights—Will Georgia Courts Agree?

The U.S. Court of Appeals for the Eleventh Circuit recently held under Georgia law that an insurance company does not waive a coverage defense by defending the policyholder in an underlying case without reserving its rights...more

Northern District of Alabama: No Bad Faith Where Insured Made Misrepresentations in Court Filings and Insurer Reasonably Relied on...

The Northern District of Alabama finds that an insurer did not act in bad faith by denying coverage for damage caused by a house fire where investigators suspected arson, the insured made misrepresentations in bankruptcy...more

Amlin v Austcorp – It’s all in the wording

In Amlin Corporate Member Ltd v Austcorp Project No 20 Pty Limited [2014] FCAFC 78, the Full Court of the Federal Court rejected the insurers’ argument that certain policies did not respond because the claim was made before...more

Welcome To The Jungle

What happens when a plan administrator relies on information received from a third party to make a denial of benefits decision under an ERISA plan? Does the plan administrator bear the burden of weighing the relative...more

Failure to File a Proof of Loss is Fatal, and the Defense Does Not Require a Showing of Prejudice

On June 3, Connecticut’s intermediate level appellate court held that the failure of a policyholder to file a sworn statement in proof of loss was fatal to his claim....more

First Circuit: Proof of Death Prerequisite to Payment of Life Benefits

The U.S. Court of Appeals for the First Circuit has confirmed that proof of death is a reasonable requirement for payment under a life insurance policy, and is a prerequisite to monies becoming “payable” under unclaimed...more

Despite Windsor, Federal Court Rejects Challenge to a Self-Insured ERISA Health Plan’s Denial of Coverage for Same-Sex Spouses

Following the U.S. Supreme Court’s decision in US v. Windsor, the requirement that an ERISA health plan provide health coverage for same-sex spouses has often hinged on whether an employee benefit plan was insured or...more

Time To Reconsider The Assignability Of Certain Claims

If an insurance company refuses to settle a claim, once liability has become reasonably clear and there is an opportunity to settle within limits, the defending insurer runs the risk of an excess verdict. Once the verdict is...more

Legislature clarifies ‘misconduct’ definition for denial of unemployment claims

For the second time in two years, the Oklahoma Legislature has passed reform related to the definition of “misconduct” as defined in the Employment Security Act. The reform provides clarification to employers as to which...more

Ninth Circuit Says Disability Plan Participant’s Claim Is Time-Barred

The Ninth Circuit in Gordon v. Deloitte & Touche, LLP Group Long Term Disability Plan, 2014 WL 1394962 (9th Cir. Apr. 11, 2014) affirmed summary judgment in favor of a long term disability plan on the ground that the...more

Sixth Circuit Revisits Controversial ERISA Decision

The Sixth Circuit Court of Appeals voted to rehear an ERISA action that awarded an unprecedented remedy for the alleged denial of long term disability benefits. The order, granting en banc rehearing, vacates a controversial...more

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