Insurers are getting hit with more class actions regarding the denial of medical treatments, like behavioral therapy treatments for autism spectrum disorders. These can be expensive: In May 2015 ConAgra Foods Inc. and Blue Cross Blue Shield were sued in a proposed class action in California, accused of denying behavioral therapy treatments for autism…

What happens when the ERISA long term disability benefit plan does not define “full-time”?

The Department of Labor says “full-time” is defined by the employer. http://webapps.dol.gov/elaws/faq/esa/flsa/014.htm

The Affordable Care Act defines  “full-time” as working 30 hours a week. https://www.healthcare.gov/glossary/full-time-employee/

When interpreting undefined ERISA plan provisions, courts apply general principles of contract law.

So, applying general…

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…