The 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
What 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
What 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
Yesterday, 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
You 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?
That subrogation claim you have might be governed by ERISA, at least in some circuits…
Here’s the case of Thurber v. Aetna Life Insurance Company, __F.3d__ (2nd Cir. March 13, 2013) (Insurer’s counterclaim for return of overpaid benefits was an equitable claim for restitution, falling under ERISA’s jurisdiction).
FACTS. Sharon Thurber broke both legs
Can 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
Here’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
How 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].
What 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…