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Tag Archives: Denial

The Basics of an ERISA Life, Health and Disability Insurance Claim – Part One: ERISA Background, Purpose and Timing Requirements

Posted in: ERISA August 12, 2019

In this several part Blog Series entitled The Basics of an ERISA Life, Health and Disability Insurance Claim, we will discuss the basics of an ERISA life, health and disability claim, from navigating a claim, handling a claim denial and through preparing a case for litigation.  In Part One of this Series, we discuss the background and purpose of ERISA, along with procedural rules and practical considerations for a disability claim.

Congress enacted the Employee Retirement Income Security Act of 1974 (“ERISA”) (29 U.S.C. § 1132(e)(2)) in response to public dissatisfaction with poorly funded pension plans, onerous vesting requirements and labor leader misuse of union benefit funds.  Senator Jacob Javits, a sponsor of ERISA, observed at the time that …

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Tenth Circuit Finds that Policy Terms in an ERISA Plan Did Not Unequivocally Grant an ERISA Administrator Discretion to Interpret Plan Terms, Applies De Novo Review

Posted in: Disability Insurance, ERISA, Insurance Litigation Blog, Policy Interpretation, Standard of Review May 17, 2019

Insurance companies acting as ERISA plan administrators often are guilty of abusing their discretion to interpret policy language related to the level of benefits payable to a claimant under a long-term disability (“LTD”) policy in a manner most beneficial to them, rather than the claimant.  In a recent decision by the Tenth Circuit Court of Appeals, Hodges v. Life Insurance Company of North America, 920 F.3d 669 (10th Cir. 2019), the court addressed the ability of insurance companies such as Life Insurance Company of North America (“LINA”) from interpreting policy language that may determine the level of benefits payable to a claimant.

In Hodges, the Tenth Circuit Court of Appeals affirmed the ruling of the district court that …

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The Basics of an ERISA Life, Health and Disability Insurance Claim – Part Three: Procedural and Practical Considerations to an ERISA Claim

Posted in: ERISA April 22, 2019

In this several part Blog Series entitled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death and dismemberment and disability claim, from navigating a claim, handling a claim denial and through preparing a case for litigation.  In Part Three of this Series, we discuss procedural considerations to an ERISA claim, as well as deadlines and timeframes to carefully monitor.

When first reviewing a potential ERISA matter, it is crucial to first determine the procedural history of your client’s claim and whether there have been any denials.  Most denial letters in ERISA cases set forth specific deadlines to file to an appeal.  In fact, the Department of …

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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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USA Today Publishes Article—Why millennials should consider disability insurance

Posted in: Disability Insurance, Insurance Litigation Blog February 08, 2019

On January 29, 2019, USA Today published an article, “Why millennials should consider disability insurance,” by Robert Powell.  The article argues for the importance of purchasing disability insurance at a young age, since most insureds are left with the financial strain of not having a stable income stream after disability.  These insureds often never consider purchasing disability insurance, or think they have enough coverage.  At McKennon Law Group PC, we see the impact of the denials of our client’s benefits every day, and fight to overturn the denial decisions of insurance claims our clients expected insurance companies to pay upon becoming disabled.  As we have seen, purchasing additional private disability insurance can prove to be crucial.

The article describes how …

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Breach of Fiduciary Duty under ERISA: Ninth Circuit Clarifies That Mere Disclosure of Plan Documents Is Insufficient “Actual Knowledge” to Trigger Statute of Limitations

Posted in: Disability Insurance News, ERISA, Fiduciary Duty, Insurance Litigation Blog, Pension Benefits, Statute of Limitations January 23, 2019

In pension and savings plan cases, it can often take several years before an employee realizes that there has been a breach of fiduciary duty.  Typically, an employee’s financial loss triggers an investigation that later reveals the facts of the breach.  But how long does an employee have to bring a claim in court?  The answer depends on the employee’s “actual knowledge” of the facts of the breach or violation.  There is a conflict among federal circuit courts of appeal on whether an employee should be deemed to have knowledge of 401(k) prospectuses and fund information simply because the employer makes this information available to the employee.  In a recent decision by the Ninth Circuit, Sulyma v. Intel Corp. Investment

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Court Says the Development of a Disabling Condition after Surgery for an Unrelated Condition Does Not Preclude Recovery of ERISA Disability Benefits under Pre-Existing Condition Exclusion

Posted in: Disability Insurance News, ERISA, Insurance Litigation Blog, Pre-existing Conditions January 16, 2019

Insurance companies often seek to exclude insureds from coverage through their long-term disability (“LTD”) plans by asserting the pre-existing condition exclusion.  If an applicant for LTD benefits has a non-disabling condition or becomes disabled as a result of a condition that developed after corrective surgery for an unrelated condition, is the applicant excluded from receiving benefits?  In a plaintiff-friendly decision, Hines v. Unum Life Ins. Co. of Am., 2018 WL 6599404 (N.D. Ohio Dec. 17, 2018), the court held that the plaintiff-disability claimant could not be excluded from coverage due to a vision disability on either the basis that she had received a diagnosis for a non-disabling condition before she became disabled or that she had developed a new …

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If You Must Miss Work Two Days a Month Due to a Disabling Condition, Are You Precluded from Working in Any Occupation Under a LTD Policy?

Posted in: Disability Insurance, ERISA, Insurance Litigation Blog, Policy Interpretation December 19, 2018

Facing a long-term disability (“LTD”) claim, ERISA plan participants under LTD policies can count on the fact that insurance companies will search for ways to escape payment of the monthly LTD benefits they promised their insureds.  These insurers often point out that insureds continue to work in their occupation between their initial diagnosis and the claim date, or that an insured’s job is sedentary and thus he or she is not precluded from performing light physical activities, or that an insured’s disabling condition is episodic and the symptoms do not render the insureds continuously disabled.  Most disability claimants have days where symptoms are better than others and therefore they cannot work continuously in any given month, missing several days of …

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Insurance Company Bias in ERISA Cases: Hartford’s History of Bias and Discovery of an Insurer’s Biased Claims Administration Process

Posted in: Abuse of Discretion, Conflict of Interest, Disability Insurance, Discovery, ERISA, Health Insurance, Insurance Litigation Blog, Life Insurance September 26, 2018

The Employee Retirement Income Security Act (“ERISA”), a 1974 federal law, sets minimum standards for many employee benefit plans and serves to provide protection for individuals in these plans.  Discovery in ERISA cases is often limited because the statute’s primary goal is to provide inexpensive and expeditious resolution to employee benefit claims.  District courts are generally limited to the administrative record unless a so-called structural conflict of interest exists.  Considering that insurers make benefit determinations on life, health and disability insurance claims and profit when an adverse decision is made, this scenario creates an inherent conflict of interest whenever an insurer administers a claim.

Courts find that a conflict of interest exists where the “entity that administers the plan, such …

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