You already know that under ERISA the court has discretion to award attorney fees to a party that has “some success on the merits.”
But what happens when the ERISA plan and the insurer are defendants, and the plan disagrees with the insurer’s denial of ERISA-governed disability benefits?
Can the ERISA plan, a nominal defendant
You already know that when a Summary Plan Description conflicts with ERISA plan language, the ERISA plan language controls.
But what happens when all you have is a Summary Plan Description (SPD), and… no ERISA Plan? Can the SPD become the Plan, and authorize subrogation reimbursement? YES.
Here’s the case of Board of Trustees/National
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.
Here’s the case of Fontaine v. Met Life, __ F.3d __ (7th Circuit, September 4, 2015) (PDF).
FACTS: Fontaine, a lawyer at Mayer Brown,
You already know that judicial review of ERISA claims generally will be limited to the administrative record considered by the claim administrator.
But the courts will allow claimants to augment the record if ERISA claims procedure was not followed.
…And courts might conclude that failing to make an IME report (obtained and relied on
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 solution, which imposes a trivial burden on plan administrators, is to require them to inform claimants of deadlines for
You probably already know that in small, wholly owned “mom and pop” businesses, benefits covering only the owners of the business may be exempt from ERISA.
But the rule has some nuances, and ERISA may apply based on who owns the business.
Here is the case of Silverman v. Unum Group, 2015
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.
Overusing the same independent medical reviewers can adversely affect the weight given to your record reviews.
And, what about independent medical exams: Are they
We see plaintiffs asserting an ERISA claim for statutory penalties more frequently now.
These claims seek statutory penalties (up to $110 per day), alleging the plan administrator “fail[ed] or refus[ed] to comply with a request for information” by the beneficiary. 29 U.S.C. 1332(c)(1).
How easy is it for plaintiffs to win a statutory
You already know that contractual limitations provisions in ERISA plans are generally enforceable and can bar untimely claims.
But when does the court apply “equitable tolling” to extend the time by which a claimant may file suit beyond the contractual limitations provision? Rarely.
And, what happens if the claim denial letter fails to set
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? Is an appeal filed on the following Monday timely?
Here’s the case of LeGras v. Aetna