2025 ERISA Year in Review: Five Pivotal Cases Reshaping Disability and Life Insurance Litigation

The landscape of ERISA litigation saw pivotal shifts in 2025, with federal courts increasingly scrutinizing the “black box” of insurer decision-making. From the Eleventh Circuit’s landmark ruling on pre-existing condition exclusions to critical procedural victories in favor of ERISA claimants/plan participants, 2025 provided clarity—and some new rules—for those navigating disability and life insurance claims.

The following five cases represent significant developments in ERISA disability and life insurance law in 2025.

1. Johnson v. Reliance Standard Life Ins. Co., 159 F.4th 1304 (11th Cir. 2025)

The Issue: The “For Which” Trap and Unsuspected Diseases

In a decision that protects claimants with difficult-to-diagnose conditions, the Eleventh Circuit addressed whether an insurer can deny benefits by retroactively linking vague symptoms to a later-discovered disease. Cheriese Johnson sought treatment for common ailments like nausea and fatigue during her policy’s three-month “lookback period,” but her actual condition—scleroderma—was not suspected or diagnosed until months after the period ended. Reliance Standard denied her claim, arguing that these symptoms were “not inconsistent” with her eventual diagnosis.

The court ruled the denial was “de novo wrong” and “arbitrary and capricious.” The court focused on the policy’s phrase “for which,” noting that it “connotes intent” and indicates the “object, aim, or purpose of an action.” Because no one “intended or even thought” to treat Johnson for scleroderma during the lookback period, she could not have received treatment for it. The court warned that the insurer’s interpretation would “warp” the policy into a pre-existing symptom exclusion, effectively allowing denials for any condition if a doctor previously recommended something as simple as drinking more water for a headache.

2. Dharmasena v. Metropolitan Life Insurance Co., 2025 WL 1563970 (C.D. Cal. May 29, 2025)

The Issue: De Novo Review and Retroactive Disability Evidence

This case is a major win for claimants seeking past benefits, especially in jurisdictions like California that restrict discretionary clauses. Applying a de novo standard of review, the court held that a claimant could establish entitlement to long-term disability (LTD) benefits for retroactive periods if the medical evidence confirms they were disabled during those times.

Significantly, the court rejected the insurer’s argument that an absence of “continuous medical care” during a retroactive period defeated a claim. The ruling emphasizes that what matters is not the frequency of physician contact, but the “totality of reliable medical evidence” demonstrating functional incapacity during the timeframe in question. This serves as a vital precedent for individuals who may have been too ill or lacked the resources to maintain constant treatment but can still prove their disability through retrospective medical analysis.

3. Hamilton v. Logic20/20, Inc. and Prudential Ins. Co. of Am., 2025 WL 3754023 & 3754065 (W.D. Wash. 2025)

The Issue: Fiduciary Breach, Waiver, and the Salyers Precedent

In these companion orders, the Western District of Washington dealt a blow to insurers attempting to deny coverage based on technicalities that were previously overlooked. A central focus of the Hamilton litigation was the breach of fiduciary duty and the doctrine of waiver. The court looked at whether an insurer could waive its right to contest eligibility if it had already accepted premiums or acted in a way that led the participant to believe they were covered.

The court leaned heavily on the Ninth Circuit’s decision in Salyers v. Metropolitan Life Insurance Co., 871 F.3d 934 (9th Cir. 2017), which held that an insurer can waive evidence-of-insurability requirements by collecting premiums without a timely objection. By applying these principles, the Hamilton court highlighted that plan administrators have a fiduciary obligation to act in the interest of participants, and they cannot sleep on their rights regarding eligibility requirements and then retroactively deny a claim once a disability occurs.

4. Rappaport v. Guardian Life Ins. Co. of Am., 782 F.Supp.3d 109 (S.D.N.Y. 2025)

The Issue: Calculating “Insured Earnings” for Business Owners

This case remains the gold standard for disputes involving high-earners and K-1 profits. The court addressed whether an owner’s share of company profits should be included in their “insured earnings” for the purpose of calculating monthly disability benefits.

The court held that when a policy’s definition of “earnings” points to income reported for federal tax purposes, K-1 profits—provided they reflect active work rather than passive investment—must be included. However, it also reminded practitioners that the lookback timing specified in the policy (e.g., the tax year prior to disability) is strictly enforced. This case underscores the need for self-employed professionals to vet their policy definitions to ensure their actual take-home income is protected.

5. Berg v. Lincoln National Life Insurance Company, 2025 WL 252481 (E.D. Wash. 2025)

The Issue: Failure to Address Treating Physicians’ Opinions and SSA Evidence

In this claimant-friendly decision, the court granted judgment to a former Walmart employee after finding the insurer’s termination of benefits was arbitrary and capricious. The court criticized Lincoln forgoing through the motions of a review while ignoring highly persuasive evidence, including questionnaires from the claimant’s treating physician and a favorable Social Security Administration (SSA) disability determination.

Applying a de novo standard, the court gave substantial weight to the treating doctor’s opinions. It found it troubling that Lincoln and its experts failed to meaningfully consider the medical assessments or the SSA’s findings. The court’s decision to award retroactive LTD benefits serves as a stern reminder that insurers must do more than just collect paper; they must meaningfully evaluate the evidence presented by the claimant’s own doctors and favorable SSA findings.

Conclusion

The ERISA landscape of 2025 reveals a judiciary that is increasingly willing to look under the hood of insurance company operations. Whether it is the Eleventh Circuit’s linguistic takedown of pre-existing condition exclusions in Johnson or the procedural openings for discovery and waiver in Hamilton, the trend is moving toward greater transparency. For plan participants, these cases offer hope that “discretion” is not a blank check for insurers. For attorneys, they underscore the necessity of building a rigorous, evidence-based administrative record from the very first day of a claim.