You know that many ERISA governed plans provide basic life insurance benefits. But what happens when the plan offers employees the choice to purchase supplemental life insurance? If the employee pays the entire premium for the supplemental benefit, is that benefit still governed by ERISA? Here’s the case of Cox v Reliance Standard Life Insurance… Continue Reading
Category Archives: ERISA
Subscribe to ERISA RSS Feed6th Circuit: Plan Administrators are NOT Necessarily Required to Obtain Vocational Evidence or an IME Before Making their LTD Determinations
Posted in ERISAGabe Baker and Steve Jensen give a good analysis of this case. In Judge v. Metropolitan Life Insurance Company [PDF], 710 F.3d 651 (6th Cir. 2013), the Sixth Circuit rejected plaintiff’s proposed bright-line rule requiring plan administrators to obtain vocational evidence and an IME before making their determination. However, those steps may be required depending on the… Continue Reading
Government Plans are Exempt from ERISA… But What is the Definition of “Government”?
Posted in ERISAYou already know that an employee benefit plan qualified as a “government plan” is exempt from ERISA’s framework. But what is the definition of “government”? Some employers may not actually be government entities, and public private partnership may inject ERISA back into the framework. This new case gives you the tests to apply to determine… Continue Reading
Converted Individual Disability Policies Governed by ERISA?
Posted in ERISAYou already know that an individual disability policy may nevertheless be governed by ERISA, even when the employee pays her own premium. This can occur when the employees benefit from a rate structure or premium discount the employer was able to negotiate in obtaining group benefits. But does ERISA apply when the employee “converts” a… Continue Reading
U.S. Supreme Court: Equity Cannot Trump ERISA Plan Terms in ERISA Reimbursement Case
Posted in Employee Benefits Litigation, ERISAThe U.S. Supreme Court yesterday strengthened the ability of employer health insurance plans to recoup payments for medical expenses paid for an injured plan participant who later sues to recover damages from a third party. The case is US Airways v. McCutchen, U.S. Supreme Court, No. 11-1285. http://www.supremecourt.gov/opinions/12pdf/11-1285_i4dk.pdf This decision helps resolve a conflict among… Continue Reading
Americans Score More Easily Seeking Social Security Disability— Reasons Why Social Security Findings Could Be Rejected by ERISA Claims Administrator
Posted in ERISAThe claimant seeking long term disability benefits under your ERISA Plan was found to be disabled by the Social Security Administration. Does that automatically mean the claimant is entitled to disability benefits under the ERISA Plan? No, but you must explain why you are taking a position different from the Social Security Administration. Met Life… Continue Reading
“Full and Fair Review” — Okay to Disclose Medical Opinions on Appeal After Appeal Denial
Posted in ERISAWhat does “full and fair” review during an ERISA appeal mean? Before the appeal decision is made, does the administrator have to disclose to the claimant medical opinions obtained during an appeal? Not if that opinion merely reaffirms or supplements the basis for the initial claim denial. Here’s the recent case of Lee v. Hartford… Continue Reading
“Appropriate Care Clause” Imposes Duty on Claimant to Seek and Accept Medical Care/Treatment Aimed at Returning Claimant to Work
Posted in ERISAWhat happens when the claimant refuses to seek and accept medical care that might enable the claimant to return to work? Does the claimant have a duty to seek out and accept medical care aimed at returning to work? YES. But there are nuances. Take a look at the recent case of Metropolitan Life Insurance… Continue Reading
Number of Employees on Disability Has Doubled in 20 Years
Posted in ERISA, UncategorizedYesterday, Jordan Weissman’s excellent article, “Disability Insurance: America’s $124 Billion Secret Welfare Program,” published March 25, 2013 in The Atlantic, explains how the number of former workers enrolled in Social Security Disability has doubled in 20 years. He states: “Since the early 1990s, the number of former workers receiving payments under it has more than… Continue Reading
Claims Administrator Does Not Have to Pay Statutory Penalties for Failing to Provide Requested Documents
Posted in ERISAYou know already that a plan administrator can be liable for statutory penalties under ERISA for failing to provide requested plan documents. But what if the claims administrator failed to provide documents Will the claims administrator have to pay statutory penalties? NO. But what if an agent of the plan administrator failed to provide documents? … Continue Reading
ERISA can apply to Individual Policies: Offering a group discount constitutes a “contribution” sufficient to create an ERISA plan
Posted in ERISACan ERISA apply to the claims made on individual policies purchased with discounted premiums? YES. Here is a great new case that highlights the analysis to establish that ERISA applies when employees purchase individual policies, with group discounted premiums. McCann v. UNUM Provident, __ F.Supp. 2d __ (D. New Jersey January 31, 2013) FACTS: Dr…. Continue Reading
ERISA: Releases Should Explicitly Release ERISA Claims and ERISA Plan
Posted in ERISA, UncategorizedHere’s a unique twist: Does that workers’ compensation settlement agreement release the ERISA disability claim? Probably not, unless the release explicitly mentions ERISA claims and the ERISA Plan. Here’s the case of Duncan v. Hartford Life and Accident Insurance Company, 2013 WL 506465 (E.D. Cal. February 8, 2013)(workers’ compensation release did not eliminate ERISA disability… Continue Reading
8th Circuit – Expressing Intent to Appeal in the Future Does Not Constitute an “Appeal.”
Posted in ERISAHow does an ERISA claimant start an administrative appeal? Can a mere request for medical records, and a reference to an “appeal in the future tense,” trigger the appeal? No. Here’s the case of Reindl v. Hartford Life and Accident Insurance Co., –F.3d __, 2013 WL 425356 ( 8th Cir. February 5, 2013) [PDF]. FACTS. Reindl… Continue Reading
ERISA: 8th Circuit–Claimant’s Contradictory Statements to SSA Can Be Used To Deny ERISA Disability Claim Involving Commissions/Bonus
Posted in ERISA, UncategorizedWhat happens when an ERISA claimant submits contradictory statements to the Social Security Administration and the ERISA plan administrator? Can these contradictory statements be used to deny the ERISA claim? YES. What’s the difference between a “Commission” and a “Bonus” in calculating a claimant’s monthly benefit? The dissent in this new decision provides guidance… Here’s… Continue Reading
ERISA: Plan Language Controls Even When an Adhesion Contract and Plan Language is “Not What a Reasonable Employee Would Expect.”
Posted in ERISAWill courts enforce Plan language even when a 24 month limitation is “not what a reasonable employee would expect” to see in a disability plan? YES. Here’s an interesting, recent case showing the power of Plan language. The opinion also supports the effect of “choice of law” provisions in Plans. Bland v. Metropolitan Life Insurance… Continue Reading
Tomorrow U.S. Supreme Court Hears Whether Equitable Defenses Can Preclude ERISA Plan Subrogation Rights
Posted in ERISAMany ERISA plans contain “subrogation” or “reimbursement” provisions. Can equitable defenses change the Plan’s reimbursement rights? You need to know about US Airways Inc. v. McCutchen — a critical case before the United States Supreme Court, with oral argument set for tomorrow. THE ISSUE: Whether “equitable defenses” can limit a plan’s recovery under ERISA §… Continue Reading
Plan Administrator “Consultation” with Plan Does Not Create Structural Conflict of Interest
Posted in ERISAWe know that an ERISA plan administrator both administering and funding the plan is operating under a “structural conflict of interest.” This “structural conflict of interest” may lower the deference a trial court will give to the plan administrator’s benefits decision. So, ERISA plans frequently delegate a plan administrator different from the funding source of… Continue Reading
Do You Have To Consider A Social Security Administration Disability Decision AFTER Appeal Denial?
Posted in ERISAWe all know that ERISA claim administrators must consider and weigh a claimant’s Social Security Administration (SSA) disability determination when deciding whether the claimant is “disabled.” But what happens when the SSA’s favorable disability determination arrives after the Plan has denied the final appeal? Do you have to reopen the claim to assess this new… Continue Reading
9th Circuit – In-House Counsel Internal Communications Before Final Appeal Not Privileged
Posted in ERISAAre in-house consultations on plan term interpretation, before a final appeal denial, privileged and confidential? NO says the Ninth Circuit… Here’s the attached case of Stephan v. Unum Life Insurance Company of America, __F.3d__, 2012 WL 3983767 (9th Cir. September 12, 2012) that highlights the point. The case also shows that: an Insurance Commissioner’s ban… Continue Reading
Failure to Exhaust Defense Trumps Missing Administrative Record
Posted in ERISAYou know you are having a bad day when you have LOST the administrative file for a claim seeking ERISA disability benefits. But is it fatal to the Plan’s defense of a decision terminating benefits? Maybe not. Here’s the case of Schorsch v. Reliance Standard Life Insurance Co., __ F.3d __ (7th Cir. August 28,… Continue Reading
Effective Delegation of ERISA Plan Administrator Duties and Standard of Review
Posted in ERISAYou probably already know that an ERISA Plan that fails to properly delegate administrative duties to another party may lose discretionary review. But does the delegation of authority have to be in writing? Maybe not, so long as the Plan allows for delegation. The recent case of Aschermann v. Aetna Insurance Company [PDF], __ F.3d__, 2012… Continue Reading
Long Term Disability — Claims Manuals Entitled to Protective Order
Posted in ERISAAre claims manuals “confidential business information” or “trade secrets” entitled to a protective order restricting dissemination? YES Can the Plaintiff’s attorney keep the claims manual for use on another case? NO. Here’s the recent opinion issued in Takata v. Hartford Comprehensive Benefit Service Company and Battelle Memorial Institute, __ F.Supp. 2d __ (E. D. Washington… Continue Reading
When Are Short Term Disability Claims NOT Governed by ERISA — This Case Explains When State Law Claims Are Not Preempted
Posted in ERISAWhen does ERISA govern short term disability payments? Take a look at this recent case, Behjou v. Bank of America et. al, [PDF] __ F.Supp. 3d __ (N.D. California May 1, 2012). FACTS: Behjou brought short term disability and long term disability claims under the Bank of America (BOA) ERISA plan. When the benefits were denied, Behjou… Continue Reading
8th Circuit — Defining the “Regular Occupation,” and the Language Needed to Confer Discretion
Posted in ERISAWe all know that ERISA disability claim decisions can hinge on the definition of the claimant’s “regular occupation” or “own occupation.” But how do you define a claimant’s “regular occupation”? Must you use the claimant’s actual duties, or can you rely upon the Department of Labor’s generic definitions contained in the Dictionary of Occupational Titles? … Continue Reading
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