What happens when an ERISA-governed disability claim is denied solely under the “own occupation” provision, but a reviewing district court concludes the claimant is entitled to “own” occupation benefits?

Does an insurer “waive” an evaluation of the “any occupation” provision because the insurer denied the claim solely on the “own occupation” standard? NO.

Can the

You already know that many state laws ban the “abuse of discretion” standard of review in denials of ERISA-governed long term disability benefits.

But self-funded ERISA plans may still apply the discretionary standard of review.

And “incorporating by reference” the Summary Plan Description (SPD) is effective in making the SPD part of the ERISA plan.

We all are seeing more “breach of fiduciary duty claims” asserted in lawsuits seeking ERISA-governed benefits.  As you know, ERISA allows participants, beneficiaries, and the Secretary of Labor to obtain relief against ERISA fiduciaries for breaching the fiduciary duties they owe to the plan or its participants. ERISA fiduciaries can also be liable under §

You know that a claimant must exhaust administrative remedies before filing a suit. But is an appeal “optional” when the denial letter says that claimant “may request a second level review”? NO.

And what’s with 502(a)(3) breach of fiduciary claims anyway?  “‘[A] review of the [ERISA] legislative history confirms that Congress did

What happens when the ERISA claimant files suit after the disability claim has been denied, and then the ERISA claims administrator reinstates benefits retroactively?

Doesn’t reinstatement “moot” the issues in the lawsuit, or make claims regarding future benefits unripe — requiring dismissal of the suit? YES it should.

And a Plaintiff’s decision to

You know that claims administrators retain experts to review a claimant’s medical and mental health condition to assess whether a claimant is sufficiently impaired to be eligible for disability benefits.

But what happens when the claimant argues that a medical opinion should be rejected due to the sheer volume of opinions the expert has provided

Some of the more challenging disability claims involve impairment resulting from Chronic Fatigue Syndrome.  There are no tests for Chronic Fatigue Syndrome, and the impairment assessment often relies heavily on self-reported symptoms and…the credibility of the claimant and the treating physician.

But there are distinct ways to help the court assess these claims. This new