News & Analysis as of

Denial of Benefits

ERISA: Can a Court Invalidate the Social Security Offset Provision Because Benefits Were “Wrongfully Denied”?

You know that most ERISA plans, and most supporting insurance policies, have provisions that allow for an offset of Social Security disability benefits. Can the court invalidate these offset provisions because of...more

Is There a Silver Lining with Hurricane Irma?

by Wilson Elser on

On September 10-11, 2017, Florida was pounded by Hurricane Irma. It appears that only northwest Florida was spared the wrath of this storm. Landfall occurred near Cudjoe Key in south Florida and for the next 24 hours the...more

Ninth Circuit Holds that ERISA Preempts State Insurance Law Bans on Discretionary Clauses for Self-Funded ERISA Plans

by Seyfarth Shaw LLP on

Seyfarth Synopsis: The Ninth Circuit Court of Appeals recently confirmed that ERISA preempts state insurance law bans on discretionary clauses for self-funded ERISA plans....more

Disability Claims Procedures Should be Updated for New Regulations

As open enrollment approaches for many benefit plans, employers and plans sponsors should check to make sure their claims procedures for disability claims are consistent with regulations that become effective for plan years...more

The Full Fifth Circuit Will Re-Visit The Standard Of Review In Denial Of Benefits Cases

by Jackson Lewis P.C. on

On July 10, the Fifth Circuit Court of Appeals announced that the full Court would re-hear a recent case concerning the applicable standard of review in an ERISA denial of benefits case – which is often outcome-determinative...more

Fifth Circuit’s Pierre Deference In ERISA Cases Trumps Texas’s Anti-Discretionary Language Statute

by DeWitt Law, LLC on

In Ariana M. v. Humana Health Plan of Texas, Inc., No. 16-20174, 2017 U.S. App. LEXIS 7072(5th Cir. Apr. 21, 2017), which involved a claim for benefits under an ERISA-governed health policy, the Fifth Circuit held that...more

Court Vacates Arbitration Award For Arbitrator’s Evident Partiality

by Carlton Fields on

A New York Court vacated an arbitration award, finding that a party appointed arbitrator’s undisclosed relationships with the appointing party amounted to a relatively infrequent instance in which such nondisclosure...more

ERISA: 4 Quick Responses to Claimant’s Typical Challenges to Disability Benefit Denials

How do you respond to typical arguments by those seeking ERISA-governed disability benefits that the claim administrator: -“cherry-picked the record”; -ignored the social security disability determination; -improperly...more

Unemployment Benefits Cannot Be Denied Based on Eight Cash Transaction Inadvertent Errors Out of 80,000 Transactions in a 21-Month...

by Ruder Ware on

The Wisconsin Supreme Court has interpreted the meaning of “substantial fault” in an unemployment insurance case, which will be applicable in worker’s compensation cases, as well. The case is Operton v. Labor and Industry...more

Three Things Health Care Employers Should Know About Affordable Care Act Section 1557

by Baker Ober Health Law on

Health care providers are likely familiar with the Affordable Care Act's (ACA) prohibitions on discriminating against the recipients of their services, but providers also must be mindful that the ACA may also make them...more

The Fifth Circuit Calls Into Question Its Standard Of Review In ERISA Denial Of Benefits Cases

by Jackson Lewis P.C. on

Explaining that “[a]s any sports fan dismayed that instant replay did not overturn a blown call learns, it is difficult to overcome a deferential standard of review,” a panel of the Fifth Circuit Court of Appeals has called...more

Back to Basics – Costly Consequences of Ignoring Process in Benefits Administration

The stories of an employer and a long-term disability insurer and claims fiduciary for an ERISA plan, defendants in two recent cases, ring so true. In the first case, the insurer was designated as claims fiduciary for an...more

Grounding Deferential Review in California – No Preemption for Discretionary Clause Ban

by Seyfarth Shaw LLP on

Seyfarth Synopsis: In a decision with wide ranging implications, the Ninth Circuit has ruled that a discretionary clause in an employer drafted plan document is subject to, and invalidated by, California’s insurance...more

Halo looms over new decision that adds to ERISA risks for claims administrators

by Thompson Coburn LLP on

The latest decision to rely on the influential Halo v. Yale Health Plan decision from the 2nd Circuit adds to a worrisome pattern of courts applying the strictest possible review to lawsuits brought by aggrieved plan...more

Labor Department Boosts Disability Claimant Protections

by Fisher Phillips on

The U.S. Department of Labor (USDOL) recently issued a final rule addressing disability benefit claims and appeals (see 81 FR 92316). The rule adds new procedural protections and safeguards meant to ensure disability...more

Final Disability Claims and Appeals Regulations – Be Prepared to Comply

by Foley & Lardner LLP on

In December 2016, the Department of Labor issued final regulations under ERISA governing claims procedures for group disability plans, which will become effective January 1, 2018. Generally, these regulations were drafted to...more

CASE ALERT: 8th Circuit Rules Against Anheuser-Busch Plan Finding That ERISA-Plan Language Must Be Interpreted According to its...

by Kiesewetter Law Firm on

Case: Knowlton, et al. v. Anheuser-Busch Companies Pension Plan — Eighth Circuit Issue Presented: Whether a plan administrator’s interpretation of ERISA-subject plan language that resulted in a denial of pension...more

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

by McNair Law Firm, P.A. on

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

by Zuckerman Spaeder LLP on

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

by Seyfarth Shaw LLP on

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

by Seyfarth Shaw LLP on

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

by Seyfarth Shaw LLP on

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

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