Can a district court consider new arguments justifying claim denial that were not articulated in the initial claim denial or appeal? NO. In fact this new Ninth Circuit decision indicates for the first time that it is “clear error” for a district court to adopt “newly presented rationale when applying de novo review.”
ERISA
ERISA: Ninth Circuit — Why Denial Letters Must Include All Rationale to be Asserted in Litigation
By Mike Reilly on
Posted in ERISA
Can a district court consider new arguments justifying claim denial that were not articulated in the initial claim denial or appeal? NO. In fact this new Ninth Circuit decision indicates for the first time that it is “clear error” for a district court to adopt “newly presented rationale when applying de novo review.”
Even…
ERISA: 7th Circuit — Can A Claims Administrator’s Errors, Made During The Initial Claim Denial, Be “Cured” During the Administrative Appeal?
By Mike Reilly on
Posted in ERISA
Can the ERISA claims administrator “cure” inadequacies, made during its initial claim denial, during the appeal process? Yes.
Did a claims administrator’s recommendation, that a claimant receive a job-accommodation, constitute sufficient proof of disability? No.
This new case highlights these issues: Canter v. AT&T Umbrella Benefit Plan No. 3, 33 F.…
ERISA (5th Circuit)-When the District Court Must Remand the Claim Back to the Administrator
By Mike Reilly on
Posted in ERISA
Sometimes an ERISA-governed disability benefit claim is denied on a specific issue that precludes the need for a full development of the record on the merits of the claim. E.g., claimant was not eligible for benefits because he was not a full-time employee at the time of disability.
But when should courts order remand…
ERISA (8th Circuit)–Now You Know Why You Should Bring Rule 52 Motions Instead of Rule 56 Summary Judgment Motions
By Mike Reilly on
Posted in ERISA
What is the most efficient way to invite the district court to resolve ERISA-benefit claims?
What’s the difference between using Rule 56 motions for summary judgment, versus a Rule 52 Motion for Judgment?
This new case highlights why Rule 52 motions may be the preferred motion to efficiently resolve ERISA benefit claims. Avenoso v. Reliance…
ERISA (5th Circuit): Plan Administrators Do Not Waive Exclusions That Develop As A Result Of Court Decisions Affecting The Disability Claim
By Mike Reilly on
Posted in ERISA
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…
ERISA – 9th Circuit: Self-Funded ERISA Plans, and Employee-Paid Supplemental Benefits: Can the Abuse of Discretion Standard Apply, Even When State Law Bans It?
By Mike Reilly on
Posted in ERISA
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.…
ERISA: 502(a)(3) Breach of Fiduciary Duty Claim DISMISSED: Repeated Calculation Errors Do NOT Involve “Fiduciary Duties”
By Mike Reilly on
Posted in ERISA
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 §…
ERISA 6th Circuit: Using the “National Economy Standard” to Defeat Disability Claims
By Mike Reilly on
Posted in ERISA
What happens when the claimant is “disabled” from performing her job with her current employer… but can perform that same job with another employer?
This issue highlights the importance of the “national economy” definition of disability as found in most long term disability policies.
Here’s the case of Holden v. Unum Life Ins.
ERISA 502(a)(3) Claims: Congress Never Thought the Phrase “Equitable Relief” Included Money Damages
By Mike Reilly on
Posted in ERISA
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…