The United States District Court for the Northern District of Indiana recently examined the issue of determining what constitutes the administrative record where an insurance company fails to meet regulatory deadlines under the Employee Retirement Income Security Act of 1974 (ERISA).  Essentially, this meant that the Court had to decide whether Reliance Standard would be able to introduce evidence before the Court that was gathered after the expiration of the time period to make a decision on the long-term disability (LTD) claim at issue.

In King v. Reliance Standard Life Insurance Company, 2024 WL 5165572 (N.D. Ind. Dec. 19, 2024) the Court decided the issue of whether defendant Reliance Standard Life insurance Company (Reliance Standard) improperly denied plaintiff Megan King’s LTD claim. The case centered around Reliance Standard’s failure to render a decision on her claim within the 45-day requirement of the Department of Labor’s (DOL) ERISA claims regulations.

King became disabled in 2018 and Reliance Standard approved her LTD claim and paid her benefits for four years. In September 2022 Reliance Standard determined King was no longer disabled and notified her that her benefits would be discontinued. King appealed in July 2023. As of September 11, 2023 King had not received a decision from Reliance Standard, nor had Reliance Standard invoked a need for additional time to review her appeal. The DOL regulations require insurance companies to provide a response within 45 days and allow them to take an additional 30 days when they are unable to complete the review due to something outside their control, though they must notify the claimant of the need for this extra time before the 45-day period runs. When King did not receive either a decision or notice of a need for additional time within 45 days, she considered her administrative remedies exhausted and filed a federal lawsuit under ERISA. Reliance Standard denied King’s appeal four months later.

The issue before the court focused on whether evidence gathered by Reliance Standard after the exhaustion deadline could be included in the court’s review. King argued that the administrative record should close once the regulatory deadlines expired, emphasizing ERISA’s strict procedural safeguards. The court agreed, granting King’s motion to exclude post-exhaustion evidence from the record. The court held that once a claim is deemed exhausted, the plan administrator cannot introduce additional evidence to justify its denial.

The court cited Fessenden v. Reliance Standard Life Ins. Co., 927 F.3d 998 (7th Cir. 2019) and determined that because Reliance Standard violated its obligations mandated by the DOL regulations, its late decision is not entitled to the deference provided by the abuse of discretion standard of review. The court therefore determined that the standard of review was de novo. The court further cited Dorris v. Unum Life Ins. Co. of America, 949 F.3d 297 (7th Cir. 2020), noting that the court can limit itself to deciding the case on the administrative record but should also freely allow the parties to introduce relevant extra-record evidence and seek appropriate discovery. The court thus found that the scope of the record is within its discretion.

On this basis, the court found in King’s favor and against Reliance Standard, reasoning that affording Reliance Standard extra time to gather evidence would undercut the benefits of King having exhausted her administrative remedies. The court concluded that Reliance Standard relinquished its opportunity to establish its evidence in the administrative record and that to allow Reliance Standard to submit its evidence after already missing the deadline would circumvent the purpose of the DOL regulation.

The court focused on the evidence Reliance Standard wanted to include in the administrative record and held that if the court allowed the inclusion of post-exhaustion evidence that creates a party’s administrative record rather than supplements it, the court would be impermissibly extending the DOL deadlines.

The King decision demonstrates the importance of understanding ERISA’s complex regulations governing employee benefits such as disability claims and the importance of utilizing the regulations to maximize a successful outcome. McKennon Law Group PC has similarly used this specific ERISA regulation to achieve success in handling its clients disability claims. Having the right ERISA disability insurance lawyer can make the difference between success and failure.

The U.S. District Court for the Northern District of California recently clarified what a claimant must demonstrate to meet the standard of “disabled” under the Employment Retirement Income Security Act (ERISA). Specifically, the court found that a claimant is not required to demonstrate absolute incapacitation but must show an inability to perform the substantial duties of her occupation

In Linda Przybyla v. The Prudential Insurance Company of America, 2025 WL 28446 (N.D. Cal. Jan. 3, 2025), the court addressed a dispute involving the denial of long-term disability (LTD) benefits. The plaintiff, Linda Przybyla, filed suit under 29 U.S.C. section 1132(a)(1)(B) after Prudential denied her LTD claim. The court’s analysis focused on Prudential’s denial process, the sufficiency of medical evidence, and the proper interpretation of “disability” under the plan.

Przybyla was employed as an “Engineering Coordinator” and participated in a group LTD plan sponsored by her employer and insured by Prudential. Under the plan, disability benefits were available if a claimant could demonstrate an inability to perform the substantial and material acts of her occupation with reasonable continuity. The plan required proof of disability, including medical documentation, treatment records, and verification of functional limitations.

The plaintiff ceased working and submitted her LTD application in November 2022 due to significant health issues, including chronic pain, dizziness, and vestibular migraines. Her treating physician, Dr. Cameron Oba, diagnosed her with fibromyalgia, ataxia, and fatigue and supported her claim. Despite this, Prudential denied the claim, citing a lack of sufficient evidence demonstrating an inability to perform her occupational duties.

Prudential’s denial relied heavily on the opinions of its medical reviewers, including Dr. Amy Cao, Prudential’s VP and Medical Director. Dr. Cao concluded that while Przybyla had mild cervical stenosis and cervicogenic headaches, the findings did not explain her reported fatigue, dizziness, or gait instability. She also emphasized that the plaintiff showed improvement with physical therapy and medication. A vocational review by Steve Lambert similarly concluded that Przybyla’s occupation could be performed at a sedentary level consistent with Dr. Cao’s findings.

Przybyla appealed the denial and submitted additional medical opinions from multiple treating physicians, including Drs. Oba and Hovsepian, who detailed persistent functional limitations and ongoing symptoms. Dr. Oba emphasized that Przybyla’s “gait difficulties/ataxia requiring a cane for ambulation” and severe fatigue were supported by his direct clinical observations, not merely subjective complaints. Despite this supplemental evidence, Prudential upheld its denial following further review by external consultants, who asserted a lack of objective findings correlating with Przybyla’s reported limitations.

The court applied a de novo standard of review and evaluated the administrative record without deference to Prudential’s conclusions. The court found that Przybyla had met her burden of proving disability under the plan, emphasizing that her medical history, consistent treatment, and the extensive documentation provided by multiple treating physicians established a significant functional impairment. The court criticized Prudential’s reliance on “selective evidence” and failure to adequately consider the consistent clinical findings supporting Przybyla’s disability. The court noted that Plaintiff’s consistent reports of pain and her efforts to obtain pain relief via physical therapy and follow-up visits with her primary care physician, neurologist, rheumatologist, and ENT support the credibility of her complaints of disabling symptoms. The court cited Sangha v. Cigna Life Ins. Co. of New York, 314 F. Supp. 3d 1027, 1036 (N.D. Cal. 2018) (“[T]he consistency and severity of Plaintiff’s complaints and her pursuit of medical treatment over time support her claim of disability”). The court further noted that Przybyla’s treating physicians’ personal and emphatic corroboration of the severity of her symptoms is further support and that given the evidence, Przybyla easily met her burden.

The court cited Muniz v. Amec Construction Management, Inc., 623 F.3d 1290 (9th Cir. 2010) and reiterated that a claimant is not required to demonstrate absolute incapacitation but must show an inability to perform the substantial duties of her occupation. The court also noted, “where the opinions of treating physicians are consistent, well-documented, and supported by the claimant’s medical history, those opinions should not be discounted in favor of non-examining reviewers.”

The court also noted that Prudential’s physicians’ opinions did not persuade it otherwise because their opinions rely entirely on the purported absence from Plaintiff’s medical records of the objective findings they believed would support her reported symptoms. However, the Ninth Circuit has repeatedly stated that objective evidence for chronic pain conditions should not be required under a disability policy. The court cited Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 678 (9th Cir. 2011) for the statement that “Many medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established until autopsy. In neither case can a disability insurer condition coverage on proof by objective indicators such as blood tests where the condition is recognized yet no such proof is possible.” It also cited Cruz-Baca v. Edison Int’l Long Term Disability Plan, 708 F. App’x 313, 315 (9th Cir. 2017) (“Pain is an inherently subjective condition.”).

Ultimately, the court ruled in favor of Przybyla, granting her motion for summary judgment and ordering Prudential to pay LTD benefits. This case underscores the importance of comprehensive medical documentation and highlights the judicial scrutiny applied to insurer denials under ERISA, emphasizing the necessity for insurers to engage in a thorough and unbiased review of all evidence presented.

If you have made or are considering making an insurance claim pursuant to the Employee Retirement Income Security Act (ERISA) or a bad faith claim, choosing the right lawyer can make a significant difference in the outcome of your case. ERISA claims and insurance disputes are complex legal matters in which having the right legal representation can be the difference between success and failure for the claim. Here are key factors to consider when selecting a lawyer to handle your ERISA or insurance claim:

1. Experience with ERISA and Insurance Bad Faith Law

ERISA is a complex federal law and ERISA claims have unique procedural requirements, including strict deadlines, and limited evidence rules. For example, if your ERISA claim for disability benefits is denied, you will generally have 180 days to submit an appeal. If you miss the appeal deadline, then file a lawsuit against the insurance company for the benefits, the insurance company will almost certainly move to have the case dismissed  for failure to exhaust administrative remedies, and you will likely lose your right to disability benefits. Choose a lawyer with specific experience handling ERISA disability claims, life insurance disputes, pension claims, health insurance claims, and accidental death and dismemberment (AD&D) cases. Verify that the attorney has a track record of successfully navigating ERISA’s administrative appeals process and litigation when necessary.

2. Knowledge of Insurance Company Tactics

Insurance companies often deny claims based on technicalities, policy exclusions, or insufficient evidence. A qualified ERISA and insurance bad faith attorney should be familiar with the strategies insurers use to deny claims and be prepared to counter them. You can gain a significant advantage in your case if your attorney understands how the insurance company and its counsel operate. For example, an attorney with experience defending claims for insurance companies who represents claimants will know how the insurance company will address any number of issues in a case. Such knowledge is a valuable asset. Robert McKennon, the managing attorney at McKennon Law Group PC, had 24 years of prior experience representing insurance companies prior to representing plaintiffs and ERISA plan participants and beneficiaries, and therefore has a deep understanding of how to deal with them.

3. Proven Success in Appeals and Litigation

ERISA requires claimants to exhaust all administrative remedies before pursuing a lawsuit; the appeals process is therefore critical. Look for an attorney who has successfully overturned claim denials at both the administrative and litigation stages. Check for settlements, verdicts, and client testimonials to assess their track record. Published court opinions, a firm’s success stories, and client reviews can provide insight into an attorney’s level of success, particularly with cases similar to yours.

4. Understanding of Medical Evidence and Expert Testimony

ERISA disability claims often hinge on the quality of medical evidence. The right lawyer should have experience working with medical experts, reviewing diagnostic reports, and presenting evidence that clearly demonstrates how the disability affects the claimant’s ability to work. For example, take an accidental death case handled by McKennon Law Group, PC. The claimant’s husband was an alcoholic who essentially needed alcohol to be able to function, so his blood alcohol level was elevated at virtually all times. In the middle of the night he got up to use the restroom then fell and hit his head. He went back to sleep. A few hours later he had a seizure. He never recovered and died in the hospital three days later. The insurance company took the position that his death was excluded from coverage based on a common exclusion found in such policies that says when a person has alcohol or another substance in his system, it is presumed that the alcohol or substance caused or contributed to the death. Because the knowledgeable lawyers at McKennon Law Group PC understood the medical evidence and the law and found a good expert to provide a report concluding that the death was not caused by the alcohol, the widow was successful in her case.

5. Clear Communication and Transparency

A good lawyer should be able to explain your legal options clearly, outline potential challenges, and keep you informed throughout the process. Look for transparency regarding fees, timelines, and case strategies during your initial consultation.

6. Familiarity with Federal Court Procedures

ERISA claims are governed by federal law and are litigated in federal court. Ensure the lawyer you choose is experienced with federal litigation and understands ERISA’s unique legal standards. If you hire a lawyer who is versed only in state law matters, you risk missing a deadline or failing to meet a requirement of the federal court and it could result in the dismissal of your case. Knowledgeable lawyers also know about the judges they appear in front of and this can be a significant help in understanding how a judge will rule.

7. Fee Structure and Costs

Understand how the attorney charges for their services. Many ERISA lawyers work on a contingency fee basis, meaning they only get paid if you win your case. Others may charge hourly or flat fees. Make sure you clarify fee agreements upfront. A prospective attorney should provide you with a draft agreement for you to review, will give you time to review it thoroughly, and will answer any questions you have about it until you have a full understanding of the terms included. Attorneys have many different types of fee agreements and some perform work on an hourly and contingency fee basis to best suit your needs.

8. Reputation and Client Testimonials

Research the attorney’s reputation within the legal community and among past clients. Look for client reviews, peer ratings, and professional recognitions that reflect the attorney’s competence and success in handling ERISA and insurance cases. On the McKennon Law Group PC website, you can find dozens of glowing review from previous clients and you will find a plethora of success stories that discuss the firm’s many successes. On this website, you will also find a biography of our attorneys and their recognitions. For example, look at the experience and professional recognitions for McKennon Law Group’s managing attorney, Robert McKennon. Compare that to any ERISA and employee benefits attorney in the country and you will find that he is at the top of the country’s legal profession.

9. Local Expertise with ERISA Claims

While ERISA is a federal law, some aspects of insurance claims can vary based on the jurisdiction, and even on the judge hearing the case. Choosing a lawyer familiar with your federal district court’s handling of ERISA cases can be advantageous. The lawyers at McKennon Law Group PC have extensive knowledge of the judges who handle ERISA matters around the United States, particularly on the West Coast.

Conclusion

Selecting the right lawyer for an ERISA or insurance bad faith claim requires careful consideration of experience, specialization, and a proven track record of success. By choosing a knowledgeable attorney who understands the intricacies of ERISA law and insurance bad faith disputes, you can ensure maximum success in your case. The lawyers at McKennon Law Group PC have all of the above and then some.