McKennon Law Group PC founding partner Robert J. McKennon was named as a 2014 “Top Attorney” by the Orange County Register’s OC Metro Magazine. This prestigious list identifies the top attorneys practicing in Orange County, California. Mr. McKennon was recognized for his work handling insurance coverage claims and litigation.
Insurers Have a Duty to Defend Where a Complaint Could Be Fairly Amended to State a Covered Liability; California Supreme Court Clarifies Duty to Defend Disparagement Claims Under Advertising Injury Coverage
An insurer has a duty to defend even if the causes of action in a lawsuit are not expressly covered by a liability policy if the factual allegations may support a potentially covered claim. This was expansive interpretation of the duty to defend adopted by the United States District Court Southern District of California in Millennium Laboratories, Inc. v. Darwin Select Insurance Company, __ F. Supp. 2d ___ (S.D. Cal. May 13, 2014). This highly significant decision further buttresses the now well-established position of courts in California that all of the facts and allegations in a lawsuit, not just the stated causes of action and facts stated in the complaint, must be considered in determining whether there exists a potentially covered claim triggering an insured’s duty to defend.
In Millennium, the insured, Millennium Labs, was covered under a commercial general liability insurance policy issued by Darwin Select Insurance Company. The policy provided coverage for “claims alleging Personal or Advertising Injury caused by an offense that takes place during the policy period.” “Personal or Advertising Injury” under the policy was defined to include, “injury, other than bodily injury, arising out of … [o]ral or written publication, in any manner, that slanders or libels a person or organization or disparages a person’s or organization’s goods, product or services.”
The insured sought coverage under the policy for two separate lawsuits involving its competitors. In the first lawsuit, the plaintiff alleged seven causes of action against the insured including: false advertising, injunctive relief and damages for violations of unfair trade practices and consumer protection statutes in various states and common law unfair competition violations. The second lawsuit was initiated by the insured, but the defendant filed counter claims against it for: interference with contractual relations, unjust enrichment and unfair and deceptive practices in violation of a state statute. Both of these actions were tendered to the insurer for defense, but the insurer denied coverage for both stating that no coverage was available for either claim under the policy because “those actions did not allege any instances of Personal or Advertising injury within the meaning of the policy.”
The insured filed suit against the insurer for coverage, alleging causes of action for declaratory relief, breach of contract and breach of the covenant of good faith and fair dealing. Thereafter, the insured moved for partial summary judgment that the insurer had a duty to defend the insured in the two actions against it and the insurer filed a cross-motion for summary judgment that it has no such duty and that it did not act in bad faith. In granting the insured’s motion for summary judgment, the district court reiterated the well-established rule in California that “the insured need only show that the underlying claim may fall within policy coverage; the insurer must prove it cannot.” Indeed, the court reaffirmed just how broad the duty to defend is in stating that “the precise causes of action pled by the third party complaint may fall outside policy coverage does not excuse the duty to defend where, under the facts alleged, reasonably inferable, or otherwise known, the complaint could be fairly amended to state a covered liability.” Based on this expansive interpretation of the duty to defend, the court found that the insured burden of showing that the underlying actions may fall within policy coverage because allegations in the two lawsuits that the insured attacked its competitors alleging that they harm patients and engaged in “bad science” fell within the ambit of the policy’s coverage for “disparagement of an organization’s goods, product or services.” Thus, the court held that the insurer had a duty to defend the insured against both claims and that the bad faith claim against it is a triable issue of fact for the jury to determine.
Not only does the court’s decision in Millennium serve as an affirmation of the breadth of insurer’s duty to defend in California, but it also expands the scope of coverage under those policy to include typically uncovered claims for unfair competition, false advertising and trademark if the claim also contains implied allegations of disparagement. This decision reminds insureds that an insurer’s duty of defend is very broad and does not turn solely on whether the stated causes of action are covered under the terms of a general liability policy and that even facts that could be reasonably alleged forms a basis for potential coverage under a liability policy.
Finally, in a similar vein, on June 12, 2014, the state Supreme Court clarified the scope of a commercial general liability insurer’s duty to defend an insured under the policy’s personal and advertising injury coverage against a claim of disparagement. In Hartford Casualty Insurance Co. v. Swift Distribution Inc., 2014 DJDAR 7443, the court held that a claim of disparagement requires a plaintiff to show a false or misleading statement that (1) specifically refers to the plaintiff’s product or business and (2) clearly derogates that product or business. Absent a claim meeting these criteria, an insurer has no duty to defend a company under a commercial general liability insurance policy providing coverage for disparagement.
Why Is It Important To Exhaust Your Administrative Remedies Under ERISA When Your Insurer Denies Your Disability Insurance Claim?
The Employee Retirement Income Security Act of 1974 (“ERISA”) provides an exclusive remedial scheme for insureds who have been denied benefits. 29 USC section 1001 et seq. Under ERISA, a plan participant may sue “to recover benefits due to him under the terms of their plan, to enforce their rights under the terms of the plan, or to clarify their rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). However, before plan participants can pursue a lawsuit against the plan/plan administrator for benefits, attorneys’ fees and costs, they must first pursue their ERISA appeal rights under the doctrine of exhaustion of administrative remedies. 29 USC section 1133. If they do not do so, they may lose all of their rights to pursue an appeal or litigation of a disability, life or health insurance claim denial.
Although not expressly set out in ERISA, federal courts require that an ERISA plan participant avail himself of a plan’s own internal review procedures before bringing suit in court. This generally means that if a claim for benefits is denied or adversely decided, the plan participant must timely file an administrative appeal with the plan administrator within the time period provided by the plan. Under ERISA, plan participants have at least 180 days to file an appeal. It is crucial for plan participants/claimants to note that, failure to request an administrative appeal within the time period provided will be deemed a waiver of their future rights to dispute the decision, including the right to file suit against the plan.
If a plan participant files a lawsuit without exhausting his administrative remedies first, the plan/plan administrator may file a motion under Federal Rules of Civil Procedure 12(b) to dismiss the case for failure to exhaust administrative remedies. The plan may even seek to dismiss the action with prejudice. Typically, courts will likely either remand the case to the plan’s administrative appeals board with instructions to hear the plan participant or dismiss the case without prejudice where it finds that the plaintiff failed to exhaust their administrative remedies prior to filing suit.
However, courts may find that administrative remedies have been exhausted even if a formal appeal was not filed where an ERISA plan fails to establish or follow the claims procedures required under ERISA. The plan participant is deemed to have exhausted the administrative remedies available under the plan and may pursue a lawsuit against the plan where: (1) the initial claims was not completed within 90 days, or 45 days for disability claims; (2) the plan administrator did not give the beneficiary written notice stating the specific reasons for the denial, and “written in a manner calculated to be understood” by the beneficiary; or (3) the plan failed to afford a reasonable opportunity to the beneficiary whose claim has been denied for a “full and fair review by the appropriate named fiduciary.” 29 USC section 1133. Additionally, because the general rule of exhaustion of administrative remedies is not a statutory requirement, a court may waive the exhaustion requirement where exhaustion would be futile.
Given the complexities involved in the ERISA claims and litigation process, it is absolutely crucial for claimants to seek the advice to attorneys who have knowledge and experience in this highly specialized area of law. The attorneys at McKennon Law Group PC specialize in handling ERISA disability insurance claims, in litigation or on appeal, and we have successfully litigated hundreds of disability insurance cases over the past 28 years.
For additional information, please see our Disability Insurance FAQs and Insurance Bad Faith FAQs.
Components of an ERISA Disability Insurance Claim
Under your employer-sponsored disability policy, you are entitled to income replacement benefits if you are disabled and unable to work due to an injury or sickness. However, recovering on the policy may involve navigating a multistep process. Below is a summary of different components to a claim for disability benefits.
Step 1: Filing Your ERISA Long-Term Disability Claim
First, Gather and request all relevant medical and occupational information. Your employer may need to provide information regarding your occupational duties and salary information. Health care providers may take anywhere from a few days to a few weeks to transmit your medical records. In the meantime, speak with your physicians/therapists about certifying your disability status in a letter to the insurer or by completion of an Attending Physician Form. Then obtain the required claim forms/plan documents from your employer. Your policy contains a description of your benefits, the definition of “disability” and applicable timelines for when to submit claims and expect decisions. Often, the plan administrator will request your medical and occupational information from your health care providers and employer, but you should maintain open lines of communication with these parties to confirm the documents are provided in a timely manner, so your claim is not delayed. Secondly, speak with your providers about certifying your disability status in a letter to the insurer. Make sure your providers understand your specific occupational duties, so that they can present a clear picture of how your disability prevents you from performing these duties. Third, keep copies of the documents you submitted, note when you submitted them and any communications you have with the insurer. Finally, if your policy specifies deadlines for filing suit, mark the dates on your calendar.
Step 2: Monitoring Your ERISA Long-Term Disability Claim
Refer to your policy for specific timeframes. Most insurers will take 45 days to issue decisions on disability claims, and in many cases, will request one or more 45-day extensions. If you do not receive any updates within the specified time period, contact your insurer for a status update. However, if you still do not receive any response beyond 45 days after the insurer received all the relevant information on your claim, consult with an experienced ERISA attorney to assess whether you can file suit based on the plan’s failure to establish or follow for claims procedures.
Step 3: Appealing an ERISA Long-Term Disability Claim Denial
If your ERISA disability claim is denied, you should receive a written denial letter from the insurer explaining the reasons for the denial. Common reasons include a lack of supporting medical documentation, or the insurer’s determination that a medical condition is not severe enough to be disabling. The denial letter may also offer guidance on what additional documents you need to submit. Typically, you have 180 days from the denial date to request an administrative appeal, or a review of your claim. If necessary, request an extension of this deadline. Mark this date on your calendar, as your failure to request an appeal by the deadline will constitute a waiver of your future rights to dispute the decision. Consult with an ERISA attorney to ensure your appeal is complete and all the relevant documents are submitted to the insurer to support your claim. As to why Often times, the insurer will not tell you that the appeal is your last chance to submit documentation needed to prove your disability claim in litigation. An attorney can make sure all deadlines are met, and your claim file is complete so you have a strong case in litigation.
To read our article on why to hire an attorney for your appeal, click here.
Step 4: Bringing Suit to Recover Your ERISA Long-Term Disability Benefits
After your appeal is denied, you may bring a suit in federal court against the plan administrator or more typically, against the claims administrator (the insurer denying the claim) for benefits, attorneys’ fees, pre-judgment interest and costs. If you have not yet done so, consult with an experienced ERISA attorney to help you file suit. Because many attorneys are unfamiliar with the intricacies of ERISA regulations and/or litigating in federal court, you should find an attorney who specializes in handling ERISA cases.
McKennon Law Group PC is extremely well suited to litigate your ERISA disability, health or life insurance claims. We are nationally recognized experts in insurance bad faith law and ERISA insurance claims appeals and litigation. With offices in Los Angeles, Orange County, San Francisco, and San Diego, contact us today to learn how our attorneys can help you with your ERISA and bad faith insurance claims.
For additional information, please see our ERISA FAQs and Disability Insurance FAQs.
Components of an Individual Long-Term Disability Insurance Claim
When you purchase an own occupation individual disability insurance policy, the insurer promises to pay for total disability or residual disability in the event you are unable to perform the substantial and material duties of your occupation due to an injury or sickness. However, recovering under your disability policy may entail a multistep process as summarized below.
Step 1: Supporting Your Long-Term Disability Insurance Claim
Gather and request all relevant medical and occupational information. Your employer may need to provide information regarding your occupational duties and salary information. Health care providers may take anywhere from a few days to a few weeks to transmit your medical records. In the meantime, speak with your physicians/therapists about certifying your disability status in a letter to the insurer or by completion of an Attending Physician Form. Make sure your physicians/therapists understand your specific occupational duties (e.g., sitting or walking for prolonged periods, using a keyboard or specific tools, lifting requirements), so they have a clear picture of how your medical condition prevents you from performing these duties. A certification letter offers strong support for your disability, describing your medical condition and the objective and/or subjective proof of your medical condition, describing your occupational duties, and describing why your medical conditions render you unable to perform the substantial and material acts necessary to the performance of your occupation in the usual or customary way and with reasonable continuity.
Step 2: Filing Your Long-Term Disability Insurance Claim
Once you have obtained the necessary medical and occupational information necessary to support your disability claim, you must file a claim for disability benefits with your disability insurance carrier. If you do not have your disability policy handy, request a copy of from your insurer. The policy contains a description of your benefits and your insurer’s definition of “disability.” Review the insurer’s definition of “disability” and compare it with the California definition. Under California law, “total disability” means that the insured is unable to perform the substantial and material acts necessary to the prosecution of your occupation in the usual or customary way and with reasonable continuity. You need only satisfy the easier of the two standards to qualify for disability benefits under your individual policy. If you believe that you qualify, request and complete the required claim forms and submit them to the insurer. Many carriers now have the forms available online. Keep copies of all the documents you submit and all communications you have with the insurer.
Step 3: Monitoring Your Long-Term Disability Insurance Claim Status
The insurer must approve or deny your claim within 30 days following receipt of all necessary information. Note the insurer may request a 30-day extension by notifying you in writing within 30 days after your claim is filed. Similarly, if the insurer requests additional medical information, they may need to have another 30 days following receipt of the requested information to issue a decision on your claim. Therefore, the faster insurers receive your medical documents and support for your disability, the sooner they will render a decision on your disability insurance claim. Make a note on your calendar of the last correspondence you had with the disability insurance insurer, and call the insurer to check the claim status if you do not receive any updates within 30 days.
Step 4: Handling a Long-Term Disability Insurance Claim Denial
If your claim is denied, review the denial letter and note the reasons provided. Common reasons for denials include a lack of supporting medical documentation, the insurer’s determination that a medical condition is not severe enough to be disabling and/or that there is no objective evidence to support your disability. If you have additional supporting documentation, you may contact the insurer to submit additional information for an appeal, or another review of your claim. However, if your documentation supports your disability, and you suspect your insurer improperly denied your claim, consult with an experienced insurance coverage attorney such as the McKennon Law Group PC to determine whether you have a good case that the law firm will take on a contingency fee basis. If your insurer breached your disability insurance contract and/or acted in bad faith, an experienced attorney can help you recover not only the policy benefits, but also emotional distress damages, consequential damages, attorneys’ fees, pre-judgment interest and punitive damages.
McKennon Law Group PC is extremely well suited to litigate your ERISA and bad faith disability, health or life insurance claims. We are nationally recognized experts in insurance bad faith law and ERISA insurance claims, appeals and litigation. With offices in Los Angeles, Orange County, San Francisco, and San Diego, contact us today to learn how our attorneys can help you with your ERISA and bad faith insurance claims.
For additional information, please see our Disability Insurance FAQs and Insurance Bad Faith FAQs.
About Directors and Officers Liability Insurance
Directors and officers liability insurance, also called D&O, covers a company’s former and current directors and officers, as well as the corporate entity, against defense fees, costs, and damages in connection with a lawsuit alleging that they committed certain wrongful acts or omissions while acting as directors and officers for the company.
Directors and officers liability insurance is liability insurance payable to the directors and officers of a company, or the company itself, as reimbursement for losses related to defense costs as a result of loss related to the legal action taken alleging the insured committed wrongful acts in their capacity as directors and officers.
D&O insurance policies may cover defense fees and costs in connection with criminal and regulatory investigations and lawsuits. D&O insurance claims potentially cover claims made by individual and company shareholders in customers, regulators, shareholder-derivative actions, and competitors.
D&O policy forms often increase legal fees and costs necessary to resolve disputes between those insured and their D&O insurers since they vary from insurer to insurer and industry to industry.
We are well suited to litigate your D&O insurance claims.We are nationally recognized experts in insurance bad faith law and litigation, and also have experience litigating D&O insurance claims. We will aggressively litigate your case to achieve success. Contact us today to learn how our Los Angeles and Orange County Attorneys can help you with your D&O insurance claims.