Ten Things to Consider and Look For in Your ERISA Life and/or Accidental Death and Dismemberment (AD&D) Insurance Plans When You Select Benefits or File a Claim

Posted in: Accidental Death or Dismemberment, Administrative Record, ERISA, Insurance Litigation Blog, Insurance Questions and Concepts, Life Insurance, Statute of Limitations March 18, 2019

1. Obtain a full copy of your plan. The full plan will not typically be a benefit summary or a print-out from a website. It will be fairly long and many definitions and it will recite your ERISA plan terms, policies and procedures for filing a life insurance or AD&D claim and handling the claim, claim denials, appeals of claim denials, etc.  The claims administrator will likely not have a copy of the full plan.  You can request a copy of the full plan from your Employer’s Human Resources department or often from the claims administrator (the insurer or third-party administrator).

2. Read the plan. Your plan document controls the rights and obligations of the parties, including all plan participants …

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Ten Things to Consider and Look For in Your ERISA Short-Term and Long-Term Disability Plans When Selecting Benefits or You Want to File a Claim

Posted in: Administrative Record, Disability Insurance, ERISA, Insurance Litigation Blog, Insurance Questions and Concepts, Statute of Limitations February 28, 2019

1. Obtain a full copy of your plan and administrative record. The full plan will not typically be a benefit summary or a print-out from a website.  It will be fairly long and many definitions and it will recite your ERISA plan terms, policies and procedures for filing a claim and handling the claim, claim denials, appeals of claim denials, etc.  The claims administrator will likely not have a copy of the full plan.  You can request a copy of the full plan from your Employer’s Human Resources department or often from the claims administrator (the insurer or third-party administrator).  You can request a copy of the administrative record from the claims administrator, which is often an insurance company such …

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Discovery Disputes in ERISA Breach of Fiduciary Duty Cases: Do the Usual Limitations Apply?

Posted in: Accidental Death or Dismemberment, Administrative Record, Disability Insurance, Discovery, ERISA, Insurance Litigation Blog, Life Insurance December 27, 2018

Discovery Disputes in ERISA Breach of Fiduciary Duty Cases: Do the Usual Limitations Apply?

The Employee Retirement Income Security Act of 1974 (“ERISA”) manages many of the benefits people receive from their employers.  These benefits include short-term and long-term disability insurance, health insurance, life insurance, accidental death and dismemberment insurance and pension plans.  When a claim under an ERISA plan is denied, the beneficiary usually must file an administrative appeal with the Claims Administrator for the benefits.  If, after filing an administrative appeal, the Claims Administrator still denies the claim, the beneficiary may sue the Claims Administrator to obtain the benefits in question.  ERISA claims differ from more traditional law suits.  A judge, not a jury, determines whether the beneficiary …

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Insurers Do Not Have Discretionary Authority, Absent Clear Language in Official Plan Documents

Posted in: Abuse of Discretion, Administrative Record, Case Updates, De Novo Review, Disability Insurance, Disability Insurance News, ERISA, Insurance Litigation Blog, Insurance Questions and Concepts, Policy Interpretation, Standard of Review April 30, 2015

In actions brought under the Employee Retirement Income Security Act of 1974 (“ERISA”), two roads diverge in federal court—and the court’s choice regarding the applicable standard of review can make all the difference in the scope of permissible evidence.  If the court applies the abuse of discretion standard of review, the court more typically (but not always) only considers evidence received by the insurer in time for its decision and limits its review to the “administrative record” to determine whether the insurer’s denial was an abuse of discretion.  Alternatively, the court may review a case “de novo,” and may consider documents not previously provided to the insurer to determine whether the insured is entitled to benefits. …

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Ninth Circuit Affirms MLG’s Six-Figure Judgment in a Disability Suit Filed Against Sun Life

Posted in: Abuse of Discretion, Administrative Record, Case Updates, Conflict of Interest, Disability Insurance, Disability Insurance News, ERISA, Insurance Litigation Blog April 29, 2015

On April 22, 2015, the United States Court of Appeals for the Ninth Circuit issued a decision affirming the district court’s decision to award McKennon Law Group PC’s client, an attorney (“insured”), his past-due ERISA plan benefits, as well as attorneys’ fees, costs and interest against Sun Life & Health Insurance Company in connection with his short-term and long-term disability insurance claim. …

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Third-Party ERISA Administrator Abused Discretion by Denying Medical Coverage: A Tale of What Not to Do

Posted in: Abuse of Discretion, Administrative Record, Conflict of Interest, ERISA, Fiduciary Duty, Health Insurance, Standard of Review September 16, 2014

Sometimes an administrator so unashamedly abuses its discretion in handling an insurance claim that its actions constitute a textbook example of “what not to do” for other administrators and the ensuing decision provides a clear illustration of how courts apply an abuse of discretion standard of review under the Employee Retirement Income Security Act (“ERISA”).  Indeed, a recent case clarified that plan administrators and third-party claims administrators alike are held to comparable standards when issuing claims decisions.  In Pacific Shores Hospital v. United Behavioral Health, 2014 WL 4086784; 2014 U.S. App. LEXIS 16062 (9th Cir. Cal. Aug. 20, 2014) (“Pacific Shores”) the Ninth Circuit Court of Appeal reversed the district court, finding the third-party administrator acted improperly by denying …

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Fighting An Insurance Claim Denial Will Often Pay Off

Posted in: Administrative Record, Disability Insurance, Disability Insurance News, ERISA, Insurance Litigation Blog, News April 21, 2011

It will not be surprising to many readers of this blog that insurance companies often deny life insurance, health insurance and disability insurance claims.  Many times, insurance companies are wrong in their decisions.   And, sometimes they acknowledge their mistakes.  The question becomes: what are the odds of an insurance company changing its mind and reversing the decision?  Our firm knows firsthand that the odds are extremely good when a reputable and respected law firm is involved in representing the policyholder’s interests.  But that is just our experience.  What is the overall experience when a health insurance claim is denied and a subsequent appeal is filed?  We now have our answer.

In his article entitled “Don’t take a health insurer’s

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Submission of the Claim File: Seal or Redact?

Posted in: Administrative Record, Disability Insurance, Disability Insurance News, Discovery, ERISA, Insurance Litigation Blog, Legislation, News June 29, 2010

For most insurance litigation, the majority of the evidence used by both sides comes from the claim file, also known as the administrative record in ERISA cases.  The claim file represents the insurance carrier’s written record of its handling and processing of an insurance claim.  Obviously, this information is highly relevant whenever coverage or a claim is disputed.  Moreover, in the case of life, health, or disability insurance cases, the claim file will also be full of personal and confidential information such as medical records and social security numbers.…

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Under Abatie, Discovery of Profitability Reports is Not Allowed

Posted in: Administrative Record, Case Updates, Disability Insurance, Disability Insurance News, Discovery, ERISA, Insurance Litigation Blog, News January 14, 2010

One of the most interesting questions in ERISA litigation is: What constitutes the administrative record for purposes of determining whether the administrator abused its discretion in making a claim determination?  Bartholomew v. Unum Life Ins. Co., 579 F. Supp. 2d 1339 (W.D. Wash. 2008) helped answer this question.

Plaintiff, who sued to recover benefits under her long-term disability (LTD) plan, sought to expand the scope of discovery under ERISA by seeking documents outside the Administrative Record. Among others, the Plaintiff requested; “Details of compensation and financial incentives,” “revenue and profitability reports for the last 10 years,” and “[a]ny document discussing the claims handling process published during the last 10 years.” Despite the recent rulings in Abatie allowing weight to …

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