This just in….

On May 4, 2020, The Department of Labor (DOL), the Department of the Treasury, and the Internal Revenue Service issued the final ruling, linked here final ruling that “extend[s] certain timeframes otherwise applicable to group health plans, disability and other welfare plans, pension plans, and their participants and beneficiaries under ERISA and

You know that ERISA requires that the claimant receive “adequate notice in writing…setting forth the specific reasons for such denial, written in a manner to be understood by the participant.”

But what is “adequate notice,” and what is the remedy if the ERISA claimant received inadequate notice?

And… is the ERISA claimant entitled to “discovery”

What happens when the Social Security Administration issues a disability finding after the ERISA administrator has issued the decision denying disability benefits?

Is the ERISA administrator obligated to reevaluate the record based on this new finding? No.

Should the Court consider this as “evidence” in a subsequent lawsuit?  No.

This new case highlights

You know that the standard of review applied by courts will significantly impact how courts view an ERISA Plan administrator’s interpretation of an undefined plan term.

But what impact should an insurer’s policy manual have in assessing the “intent” of a plan term?  NOT MUCH.

This new case highlights both points.

Caldwell v. Unum

You already know that ERISA regulations set specific timelines for the issuance of ERISA-governed long term disability decisions. See, e.g., 29 C.F.R. 2560.503-1(i)(1)(i) (45 days for disability claims and 60 days for others). In special circumstances, the administrator can extend the time by which benefit decisions are made.

An administrator’s failure to issue benefit

What does it mean to be totally disabled from the “regular occupation”? 

Is “regular occupation” defined as the duties the claimant is actually doing in his or her specific job?  NO.

Each claim should be assessed from the perspective of duties of the job generally in the national economy and not how the job