Denial of Benefits

News & Analysis as of

ERISA: Fibromyalgia – “[D]iagnosis is not the automatic equivalent to a finding of disability.”

Fibromyalgia cases often are difficult to assess in determining eligibility for benefits. But the mere diagnosis of a condition (like fibromyalgia) is not enough to qualify for disability benefits under most policy...more

Court upholds South Carolina company's benefits plan decision

One of the most important components of the employment relationship is the benefits package an employer is able to offer its employees. Employee benefits have to make business sense for the employer because there’s always a...more

ERISA (D.C. Cir.): Do You Know the Difference Between a “Payroll Practice,” and Short Term Disability Benefits Governed by ERISA?

What happens when an employer provides a disabled employee continued regular wages, paid out of general employer assets? This is known as a “payroll practice”… and ERISA may not apply. A new case that highlights the...more

“Change of Control” Case Isn’t Governed By ERISA, Court Rules

When an employee brings a lawsuit involving a plan adopted by their employer, one question is whether ERISA—the Employee Retirement Income Security Act of 1974—applies....more

Court Smacks Down Plaintiff’s “[But Mom…] Everyone Else Is Doing It” Public Policy Argument To Void Illegal Exclusions Provisions

Seyfarth Synopsis: A Court ruled that under the Affordable Care Act, an ERISA governed plan exclusion cannot unequivocally bar emergency medical care related to injuries sustained in a fireworks explosion. Recently, a...more

Evidence From LinkedIn, IMDB Used to Support Denial of Benefits

Be careful what you ask for. The Plaintiff in a recent case from the Central District of California learned that lesson when the Plan’s re-evaluation of her claim for benefits revealed that she was apparently working as a...more

Mon General Hospital to Settle Discrimination Charge Filed By Female Employee Denied Benefits For Same-Sex Spouse

Employee Benefits No Longer Exclude Coverage for Same-Sex Spouses - MORGANTOWN, W.V. -- Mon General Hospital has agreed to conciliate a charge of sex discrimination filed by its employee, Kathy McIntire, alleging that...more

A Question of Timing – Social Security Disability Determinations and the Administrative Record

Seyfarth Synopsis: Court excludes evidence of Social Security disability award issued after the final decision issued on plaintiff’s claim for plan disability benefits. The decision accentuates the importance of fighting to...more

Dealing with Long-Winded Out-of-Network Provider Nuisance Letters

Over the past couple years, more and more of my clients with self-funded plans have received letters from out-of-network providers appealing denied claims. The letters are usually 20 to 30 pages long, not very specific, and...more

UnitedHealth Plan Holders Win Class Certification in ERISA Lawsuit

The District Court for the Northern District of California recently granted certain members of UnitedHealth health plans class certification in their suit alleging improper denial of benefits. Plaintiffs in the putative...more

Hold on to Your (Top) Hat: ERISA Section 502(a)(3) May Be Used to Enforce the Terms of a “Top-Hat” Benefits Plan

Thanksgiving is typically a time for gratitude, gathering with family, and acts of kindness among fellow men and women. But in one recent case, a bank used Thanksgiving to force-feed a separation agreement to its outgoing...more

Long Term Disability Payments: Standard for Abuse of Discretion

Insurance for long term disability – payments to an insured who is prevented from earning his or her income due to long term disability – is a fruitful field for litigation for many reasons. Though the insurance may be...more

ERISA — 7th Circuit: Under De Novo Review, the Court “Should NOT Resolve[] Doubts or Gaps in the Evidence in [the Claimant’s]...

You know that claimants have the burden to establish eligibility for ERISA-governed disability benefits. Sometimes gaps in coverage can occur when, for example, a claimant alleges disability while using accrued vacation....more

Health Update - July 2016

The Vulnerability of Healthcare Information - According to a report the Brookings Institute issued in May 2016, 23% of all data breaches occur in the healthcare industry. Nearly 90% of healthcare organizations had some...more

California Supreme Court Clarifies Constitutional Limits on Punitive Damages

In Brandt v. Superior Court, the California Supreme Court held that when a plaintiff proves that an insurance company withheld policy benefits in bad faith, attorneys' fees reasonably incurred to compel payment of the...more

Wisconsin Court of Appeals Rejects Labor and Industry Review Commission's Worker's Compensation Determination as Unreasonable

Circuit courts and appellate courts commonly apply “great weight deference” to worker’s compensation benefit determinations made by the Labor and Industry Review Commission (“LIRC”), but not this time. In an unpublished...more

ERISA — 9th Circuit: Plaintiffs Can Now Simultaneously Bring Benefit Payment and Equitable Claims

Lane Powell attorney Mike Baylous writes an excellent summary here on big changes to ERISA in the 9th Circuit. Remember that old argument that equitable claims should be dismissed because they are duplicative?...more

Second Circuit Applies Stricter Rules for a Plan Administrator’s Noncompliance with Benefit Claims Regulations

In Depth - On April 12, 2016, the US Court of Appeals for the Second Circuit in Halo v. Yale Health Plan, 2016 WL 1426291 (2d Cir. Apr. 12, 2016), addressed various issues that could arise during a plan administrator’s...more

Judge Garland’s ERISA Jurisprudence Reflects His Methodical and Moderate Reputation

With President Obama’s recent nomination of Judge Merrick B. Garland of the U.S. Court of Appeals for the D.C. Circuit to the U.S. Supreme Court, we thought our loyal readers would be interested to learn a little about Judge...more

Statutory and Contractual Limitations Periods and the Events that Trigger Them: Insight from the Fourth Circuit

The Employee Retirement Income Security Act of 1974 (ERISA) does not contain a statute of limitations provision, and courts generally apply the most analogous state law statutory limitation. However, some plans fill the void...more

Anti-Assignment Provision Bars Surgery Center’s $3.3 Million ERISA Benefits Claims

A federal district court in California held that the ILWU-PMA Welfare Benefit Plan’s anti-assignment provision barred Brand Tarzana Surgical Institute’s claim for benefits and thus dismissed the Institute’s claim for...more

ERISA: Sixth Circuit — No Conflict of Interest with Multi-Employer Benefit Plan, Saving Abuse of Discretion Standard of Review

You already know that evidence of a “conflict of interest” can change the standard of review the court applies in ERISA claims. But proper structuring of multi-employer benefit plans can avoid an inherent conflict of...more

Coverage for Direct Physical Loss Does Not Necessarily Include “Matching” or Require “Aesthetic Uniformity”

When a property insurance policy covers a multi-story building or multi-building property, and a portion sustains damage, there is often a question regarding the extent to which undamaged property should be replaced to ensure...more

Fifth Circuit Upholds ERISA Disability and Life Benefit Denials

In two decisions issued last month, the Fifth Circuit upheld ERISA plan denials of disability and life benefits, confirming its deferential approach in most ERISA benefit cases....more

Notice of Plan-Imposed Statute of Limitations for Filing Suit Must Be Included in Adverse Benefit Determination Letters

In Mirza v. Insurance Administrator of America, 800 F.3d 129 (3rd Cir. 2015), the court held that adverse benefit determination letters must include any plan-imposed time limits for seeking judicial review to be enforceable....more

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