Denial of Benefits

News & Analysis as of

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

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 In an unpublished...more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

Sub-Assignee Has Standing To Assert ERISA Claims

The Eleventh Circuit held that a sub-assignee’s claim for payment of a chiropractor’s bills against Blue Cross and Blue Shield of Florida were within the scope of ERISA and thus determined that the district court properly...more

Pennsylvania Unemployment Officials Announce Change to Fact-Finding Process

According to a recent announcement by the Office of UC Service Centers, employers in Pennsylvania can expect that telephone calls will now be part of the state’s fact-finding process in connection with initial eligibility...more

Court Crushes Constitutional Challenge To Independent Medical Review

In Frances Stevens v. Workers’ Compensation Appeals Board, Outspoken Enterprises, Case: A143043 1st District, Division 1, the California Court of Appeal upheld the constitutionality of California Labor Code Section 4610.6...more

Michigan Court Dismisses Cross-Claim as Insurer Not Properly Subject to a Claim for Breach of Fiduciary Duty

In Van Loo v. Cajun Operating Co, No. 14-cv-10604 (E.D. Mich. Sept. 17, 2015), the Eastern District of Michigan, a Sixth Circuit district court, held that the requirement for evidence of insurability was triggered based on...more

Seventh Circuit Rules ERISA Does Not Preempt State Law Prohibiting Discretionary Clauses

In Fontaine v. Metropolitan Life Ins. Co., No. 14-1984, 2015 U.S. App. (7th Cir. Sept. 4, 2015), the Seventh Circuit affirmed a U.S. District Court for the Northern District of Illinois decision holding that Illinois’s...more

Seventh Circuit Rejects In-Network Providers’ Bid For ERISA Claims Procedures

Claims by providers seeking to assert the rights of ERISA plan participants have been percolating in courts throughout the country. The Seventh Circuit has now weighed in, rejecting the notion that providers who have payment...more

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

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