Denial of Benefits

News & Analysis as of

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

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

83 Results
|
View per page
Page: of 4
JD Supra Readers' Choice 2016 Awards

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:

Sign up to create your digest using LinkedIn*

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.

Already signed up? Log in here

*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.
×