Denial of Benefits

News & Analysis as of

4th Circuit Holds Insurer Not Equitably Estopped From Denying Coverage

In an unpublished opinion, the 4th Circuit Court of Appeals reversed a South Carolina District Court judge’s finding that an insurer was equitably estopped from denying coverage to a new owner of the insured business for a...more

Sixth Circuit to Revisit Unprecedented Expansion of ERISA Wrongful Denial of Benefits Remedies

On December 6, 2013, in Rochow v. Life Insurance Company of North America, 737 F.3d 415 (6th Cir. 2013), the Sixth Circuit affirmed a district court ruling that an insurance company that improperly denied ERISA disability...more

ERISA: 10th Circuit — How to Win Two Frequent Challenges to ERISA Benefit Denials

How do you defeat two arguments frequently used to challenge an ERISA-governed disability claim denial? Argument (1) the rationale for the claim denial changed, or Argument (2) the denial letter failed to tell...more

ERISA – 11th Cir. — Social Security Determinations Issued AFTER Initial Claim Denial Must Be Considered?

You already know that a Social Security disability (SSDI) decision should be considered in the context of deciding whether the claimant is disabled under the terms of the disability policy....more

Employee Benefits Developments - January 2014

CASES - Court Finds Former NFL Player’s First Wife Is Surviving Spouse - A recent decision by the U.S. Court of Appeals for the Third Circuit demonstrates once again the importance of divorcing your first spouse...more

Not All Policies Are Created Equal: Evergreen State Appeals Court Blocks Policyholder Reach to Excess Insurance After Settlement...

The decision in Quellos Group LLC v. Federal Insurance Co., No. 68478-7-1 (Wash. Ct. App. Nov. 12, 2013) is a reminder that vague policy language can be costly. You may not have access to your excess insurance funds. The...more

Texas Supreme Court Rejects Insurer Attempt to Expand Limited Insurance Exclusion for Liability Assumed by Contract, Holding that...

In a highly anticipated ruling earlier this month, the Texas Supreme Court rejected Amerisure Insurance Company’s attempt to radically expand the scope of a common exclusion for liability assumed by contract found in many...more

Plaintiff Counsel’s Impact on Limitation Periods

The recent decision in Conrad v. State Farm confirms once again that a Plaintiff cannot successfully argue that they did not understand that an Explanation of Benefits (OCF-9) terminating or denying benefits starts a...more

Court’s Award of $3.8 Million Raises Questions About the Scope of ERISA Remedies

The U.S. Court of Appeals for the Sixth Circuit has affirmed an unusually large award of $3.8 million in a case involving the denial of long-term disability benefits. In Rochow v. Life Insurance Company of North America, No....more

CMS Issues Refunds For Collections Made On Incorrectly Identified Incarcerated Beneficiary Overpayments

Medicare does not cover supplies or services for persons who are incarcerated at the time the services are rendered. However, Medicare had purportedly paid providers in error for many such claims and sought to recover those...more

Health Plan Class Action Lawsuit Filed in Northern California

Approximately 300 employers and other organizations, many of which are in Northern California, were named as co-defendants in an ERISA class action lawsuit filed on November 22, 2013, in the U.S. District Court for the...more

CMS to Postpone Denying Claims When Ordering/Referring Provider Not Enrolled in Medicare

The Centers for Medicare & Medicaid Services will implement edits on providers ordering/referring Part B, durable medical equipment and Part A home health agency claims effective January 6, 2014....more

Insurer’s “Premonitions” Accurate in Claim Involving Psychic Group: No Coverage for Second Suit Alleging Same Wrongful Acts as...

In Zodiac Group, Inc. v. Axis Surplus Ins. Co., _____ Fed. Appx. _____, 2013 WL 5718439 (11th Cir. (Fla.) Oct. 22, 2013), the United States Court of Appeals for the Eleventh Circuit considered whether facts alleged in an...more

Supreme Court to Review Statute of Limitations for Denial of ERISA Claims

On Tuesday, October 15, 2013, the United States Supreme Court heard oral arguments in a case likely to have wide-ranging consequences for employers who offer employee benefit plans under Employee Retirement Income Security...more

Do I Have To Go To Court To Dispute Denial Of My NJ Workers’ Compensation Claim?

When your claim for Workers’ Compensation is denied, you have the right to dispute the decision. Disputes are reviewed in a hearing before a judge of compensation within a district office of the New Jersey Department of Labor...more

ERISA: Deference to Claim Decision Should INCREASE When Partial Benefits Granted

Did you know that awarding at least some benefits, rather than denying benefits entirely, helps prove the claims administrator is “unbiased”? Also, when there are sharp conflicting opinions between the claimant’s...more

CMS Releases Temporary Instructions for Implementation of Final Rule 1599-F for Part A to B Billing of Denied Hospital Inpatient...

On September 16, CMS released a Medicare Learning Network (MLN) article (SE 1333) detailing temporary instructions for the implementation of final rule 1599-FI relating to billing for Part B services that were provided during...more

Spotlight on Louisiana: Department of Revenue Denies Marriage Benefits to Same-Sex Couples

On September 13, 2013, in Revenue Information Bulletin No. 13-024, the Louisiana Department of Revenue (Department) announced that for Louisiana tax filings purposes, the Department will not recognize same-sex marriages. This...more

Stresscon v. Travelers: A Victory For Policy Holders

Yesterday, the construction and insurance communities received much sought-after guidance from the Colorado Court of Appeals regarding Colorado’s recently adopted bad faith statute in the highly anticipated decision,...more

Life Insurance Beneficiary Who Murdered Policyholder Is Not Entitled To Benefits

Applying the common law “slayer rule,” a federal district court in New York held that a beneficiary of an ERISA-governed life insurance plan forfeit his claim to insurance proceeds after he pled guilty to murdering the...more

CMS Reinstates Policy for Enrollment Denials Related to Unpaid Medicare Overpayments

The saga related to CMS’ policy to deny enrollments based on a history of unpaid Medicare debts continues. We first reported on the proposed regulations and corresponding policy announcement, via Transmittal 469, expanding...more

The Non-Response (De Facto) Denial

Injured workers have the right to file an appeal if the claims adjuster does not respond to a written request within 30 days. Attorneys are usually the only ones that know that when the adjuster fails to respond, it is...more

Insured Seeking Defense and Indemnity Forced to “Go Fish” After Failing to Satisfy Policy’s Condition Precedent

In Petco Animal Supplies Stores, Inc. v. Insurance Co. of North America, ___ F.3d ___, 2013 WL 3942889 (8th Cir. Aug. 1, 2013) (Minn.), Meiko Pet Corporation, a Taiwan company, purchased a products liability insurance policy...more

CMS Temporarily Rescinds Implementation of Enrollment Denials Related to Unpaid Medicare Overpayments

In the June 12, 2013 Payment Matters article “Enrollment Rules Continue To Provide Expanded Bases For Enforcement,” reference was made to CMS’ publication of Transmittal 469 to the Medicare Program Integrity Manual....more

Alabama Policyholder’s Bad Faith Claim Barred Where Basis of Coverage Denial Was Debatable Under Alabama Law

The U.S. District Court for the Northern District of Alabama, Southern Division, recently granted an insurer’s summary judgment with respect to a policyholder’s tort claim for the bad faith refusal to pay a claim, dismissing...more

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