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Tag Archives: insured

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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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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The Basics of an ERISA Life, Health and Disability Insurance Claim – Part Two: Plan and Claims Administrators

Posted in: ERISA, Insurance Litigation Blog April 01, 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 and disability claim, from navigating a claim, handling a claim denial and through preparing a case for litigation.  In Part Two of this Series, we discuss the roles of various Administrators, the administrative record and the laws requiring Administrators to provide their records to a claimant.

Two different entities manage an ERISA plan: the Plan Administrator and the Claims Administrator. Oftentimes, the two roles are performed by different entities.  The Plan Administrator manages and sponsors the plan and must ensure that the plan complies with applicable regulations.  The Plan Administrator is often …

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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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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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Attending Physician’s Certifications of Disability: How Important Are They for Disability Insurance Claims Under ERISA?

Posted in: Disability Insurance, ERISA, Insurance Litigation Blog, Social Security Administration September 14, 2018

Many employees are covered by group short-term disability insurance and/or group long-term disability insurance.  These plans provide benefits to employees who cannot return to work because of illness or injuries that prevent them from performing their work activities.  The Employee Retirement Income Security Act of 1974 (“ERISA”) governs most of these insurance plans.  Unfortunately, sometimes an insured becomes disabled and must support his claim for disability benefits.  The insured’s attending physician typically has examined the insured and determines that he cannot return to work.  The insured will want to use his physicians’ certification of disability to support his disability by submitting it to his insurer.  A common question is:  Must an insurance company accept the treating physician’s opinion regarding the …

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“Sole Cause” Provisions in Accidental Death and Dismemberment Policies: Are ERISA Claimants Getting a Fair Shake?

Posted in: Accidental Death or Dismemberment, ERISA, Insurance Litigation Blog, Policy Interpretation August 22, 2018

According to the Centers for Disease Control, unintentional injury is the leading cause of death among people ages 1 to 44.  For this reason, Accidental Death and Dismemberment (“AD&D”) Insurance should be an essential component of insurance coverage for most families.  As preventative care expands and baby boomers remain active, accidental deaths will likely continue to rise as the leading cause of death among individuals.  While AD&D coverage is important to protect families from unforeseen injuries and death that can have severe financial repercussions, insurance companies do not like to pay these claims as they often attempt to limit the scenarios in which an insured can recover an AD&D benefit by placing “sole cause” provisions in AD&D policies.  These provisions …

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Where Did My Long-Term Disability Benefits Go? Termination of Benefits Without Improvement of Insured’s Medical Condition

Posted in: Accidental Death or Dismemberment, Disability Insurance, ERISA, Insurance Litigation Blog August 15, 2018

Many people purchase accidental death and dismemberment insurance or disability insurance to protect themselves should they ever become injured and unable to work.  If they become injured, they file a claim with their insurance company, and, after a potentially lengthy process, the insurance company may start to pay disability or accidental death and dismemberment benefits.  Sometimes, however, after initially paying disability benefits, an insurer will suddenly change its stance on the insured’s disability and terminate the benefits.  But there is a problem: The insured has not recovered, and his medical condition has not become better.  The insured still cannot return to work.  If the insured was disabled, and nothing has changed, why the sudden termination of benefits?  Thankfully, courts also …

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The Latest Frontier for Forum Selection Clauses: ERISA Policies

Posted in: Accidental Death or Dismemberment, ERISA, Health Insurance, Insurance Litigation Blog, Life Insurance July 26, 2018

Letters denying an insured’s claim often end by listing what steps an insured can take to challenge an unfavorable determination.  Assuming all administrative appeals have been exhausted, this generally involves filing a lawsuit. Depending on the language in the underlying insurance policy, the denial letter may state that if an insured wishes to bring suit, they must bring suit in a specific court in a particular state that could be on the other side of the country.  Clauses in contracts, such as insurance policies, that require filing suit in a particular jurisdiction are called “forum selection clauses.”

Courts often enforce forum selection clauses.  When determining whether to enforce a forum selection clause, a court will ask if the forum selection

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Agents, Brokers and Rescission of Insurance Policies

Posted in: Accidental Death or Dismemberment, Agent/Broker, Disability Insurance News, Insurance Bad Faith, Insurance Litigation Blog, Life Insurance, Long Term Care Insurance April 09, 2018

Generally, an insurer need not investigate statements made in an application for insurance, subject to certain exceptions. Instead, the potential policyholder or applicant must fully disclose all known material information. If a potential insured does not correctly disclose information on an application (even innocently), the insurer may later try to rescind the insurance policy. When an insurer “rescinds” a policy, it renders the contract as if it never existed and frees both parties from their obligations under the contract. Practically, this means that the insurance company is no longer obligated to pay the claims for life insurance, accident insurance, health insurance, long-term care insurance or long-term disability insurance benefits and the policyholder no longer has to pay the policy’s premiums. …

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