Denial of Benefits

News & Analysis as of

Texas Surgical Centers: Aetna Improperly Denies or Underpays Out-of-Network Claims

Aetna is now facing another set of claims calling into question its determination and payment methodology for out-of-network reimbursement. On September 4, 2015, six surgical centers in Texas (Allied Center for Special...more

Veteran Receives Compensation for Injury After Pro Bono Battle

Baker Donelson lawyer Frank S. James, together with the veterans legal clinic at the University of California at Berkeley, scored a victory recently in a long and hard fought battle to obtain military insurance benefits for...more

ERISA — 7th Circuit: Illinois State Law Ban On Discretionary Clauses Upheld

You already know about the big trend in states to ban discretionary clauses in insurance policies that fund ERISA benefits. Chalk up another circuit deciding to enforce the ban....more

Second Circuit Reinstates Mental Health Parity Case Against UnitedHealth

In late August the U.S. Court of Appeals for the Second Circuit reinstated a lawsuit by a physician association against a third-party plan administrator. The case against UnitedHealth Group and related entities (United) had...more

Seventh Circuit Finds that State Insurance Law Applies, Resulting in De Novo Review of Benefit Claim

On September 4, 2015, the U.S. Court of Appeals for the Seventh Circuit ruled in Fontaine v. Metropolitan Life Insurance Company that the Employee Retirement Income Security Act of 1974, as amended (ERISA), does not preempt...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

The Third Circuit Requires Benefit Denial Letters to Contain Plan Limitations Period

In Mirza v. Insurance Administrator of America, Inc., No. 13-3535 (3d Cir. August 26, 2015), the Third Circuit became the latest Court to require benefit denial letters to include a notification of the plan’s limitations...more

ERISA Plan Can't Shrink Deadlines Without Providing Notice, Says 3rd Circuit Court of Appeals

The 3rd Circuit Court of Appeals just ruled that an ERISA plan can’t shorten the deadline for filing a legal action challenging a denial of benefits unless the participant receives written communication of the plan’s altered...more

ERISA (Sixth Circuit) — Medical Reviews: You Need to Explain WHY You are Rejecting the Treating Physician’s Opinions; and Don’t...

You already know that you do not have to give special deference to the opinions of treating physicians. But you need to explain why the treating physician’s opinions are being rejected....more

Potential Erosion of the Distinction Between Benefits Denials and Breach of Fiduciary Duty under ERISA in the Tenth Circuit

A recent decision from a federal district court in the Tenth Circuit provides an example of the potential erosion of the distinction between claims for wrongful denial of benefits and breach of fiduciary duty under the...more

Ninth Circuit Affirms “Absurd” Denial of Insurance Coverage, Highlighting Important Considerations for Marine Insurance...

Marine insurance policyholders should be aware that the laws governing marine insurance are not always favorable to them. A recent decision from the United States Court of Appeals for the Ninth Circuit is the latest example....more

ERISA (9th Cir.) A Day Late, But Not A Dollar Short — Counting The 180 Day Appeal Period Gets Easier For Claimants

You know that under ERISA regulations a claimant has at least 180 days to appeal a benefit denial. ERISA plans set out contractual timelines for appeals. But what happens when that 180 day period runs out on a weekend?...more

En Banc Mississippi Court of Appeals Affirms Summary Judgment for Insurer, Adjuster and Employer on Bad Faith Claims Arising from...

Chapman v. Coca-Cola Bottling Co., No. 2013-CA-01883-COA (Miss. Ct. App. Mar. 17, 2015). Ruling en banc, court affirms grant of summary judgment for insurer, adjuster and employer on bad faith claims brought by former...more

Sorry, But Your Reservation Has Been Cancelled: How an Insurance Company’s Failure To Give Proper Notice of Its Reservation of...

Most courts hold that an insurance company will not be estopped from denying coverage, even if the insurance company participates in the defense, provided it gives timely notice to the policyholder through a reservation of...more

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

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