Articles Posted in ERISA

Here is yet another ERISA claim being denied by the Federal Courts.  This case is from the United States Fifth Circuit Court of Appeals and is styled, Deo G. Shanker v. United Omaha Life Insurance Company.

The District Court granted United’s summary judgment motion and this appeal followed.

Shanker was President of a company called Intracare and United was the insurer under an ERISA plan which provided for long-term-disability (LTD) benefits.  To qualify for LTD benefits, Shanker had to become “Disabled due to an Injury or Sickness, while insured under the Policy.”  Disabled is defined to mean: “Because of Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred in which you are prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis ….”  Material Duties is defined as “the essential tasks, functions, and operations relating to an occupation that cannot reasonably omitted or modified” and includes “the ability to work for an employer on a full-time bases.”  Regular Occupation is defined as “the occupation You are routinely performing when Your Disability begins.”  The definition in the policy also notes:

ERISA lawyers are quick to tell potential clients the limitations of ERISA claims.  One of those limitations is that little to no legal discovery is allowed in ERISA claims.  This is discussed in an April 2019, opinion from the Northern District of Texas, Dallas Division.  The case is styled, Jose Chavez v. Standard Insurance Company.

In this lawsuit, Chavez is seeking long term disability (LTD) benefits from Standard.

Chavez filed suit against Standard in sought to compel discovery of contractual and financial arrangements under which Standard’s medical consultants played their respective roles regarding Chavez’s LTD claim.  Chavez also sought discovery of Standards internal claim procedures.

After reporting just a few days ago about a significant victory on an ERISA case, today we are reporting on a loss from the 5th Circuit.  This case is from Eastern District of Lousiana but the appeals court is the 5th Circuit which is the same appeals court for cases out of Texas and the court that Texas courts are to look to in rendering their decisions.  The case is styled, Amanda C. Foster v. Principal Life Insurance Company.

Amanda worked as an attorney when she started experiencing intractable migraine headaches that made work impossible.    Amanda applied to Principal for long term disability (LTD) benefits.  After multiple reviews by various healthcare providers Principal denied her claim, concluding Amanda was not disabled within the meaning of the policy.

As in most disability claims, the reports from various medical providers for the claimant are voluminous and lengthy, as are the reviews by the doctors hired by the insurer to review the claim.

Insurance attorney who handle denied claims and in particular insurance attorneys who are willing to take on an insurance claim governed by ERISA claim which has been denied, needs to read this opinion from the Eastern District of Texas, Sherman Division.  The case is styled, Gina Pike v. Hartford Life And Accident Insurance Company.

Pike had received long term disability (LTD) benefits from Hartford from April 24, 2008 through December 14, 2016, the period of time when Hartford determined Pike met the definition of disability in the LTD policy.  Later, after determining Pike was unable to prove she continued to be disabled under the policy, the benefits ceased on December 15, 2016.

This case resulted in a 51 page opinion which is not going to be discussed at any length here.  What is relevant is that it is rare for beneficiaries of these employer sponsored benefit plans and as a result needs to be carefully read to determine what the Court saw that separated this case from other ERISA cases.

Lawyers who handle ERISA cases always have to explain to their clients that in ERISA cases, the administrative process has to be completed before a lawsuit can be filed.  This is illustrated in this 2019 opinion from the Southern District of Texas, Houston Division case styled, Lisa K. Bunner v. Dearborn National Life Insurance Company, et. al.

This case arises out of denial of long-term disability benefits to Lisa contained in her employee welfare benefit plan.  This case is governed by the Employee Retirement Income Security Act of 1974 (ERISA).

The details of this case can be read in the opinion.  What is relevant here is the Court stating / emphasizing the requirement that the administrative process be exhausted prior to filing a lawsuit.

Here is another case for life insurance lawyers to read and make part of their knowledge of life insurance cases involving ERISA.  The case is from the Northern District of Texas, Dallas Division.  The case style is, Stephanie Taylor v. Metropolitan Life Insurance Company.

This ERISA life insurance case was decided on motions for summary judgment in favor of MetLife.

Stephanie is the beneficiary under a policy of life insurance insuring her husband, Jonathan.  They had a policy of Basic Employee Life Insurance for $136,000 and $271,000 of Supplemental Employee Life Insurance.

How does Federal law work with the Texas Slayer Statute, Texas Insurance Code, Section 1103.151?

This question is answered in the 1992, Fifth Circuit opinion styled, Metropolitan Life Insurance Co. v. White.

This is a summary judgement case.  Terri Yohey was the named insured under a group life insurance policy issued by Metropolitan under the Federal Employees Group Life Insurance Act (FEGLIA).  At the time of her death she had not designated a beneficiary.  Her widower, Leslie Yohey, was convicted of her murder.

What happens when the named beneficiary on a life insurance policy intentionally causes the death of the insured?  That was the question in this case from the Western District of Texas, San Antonio Division, opinion styled, Garrett Bean and Aneila Bean v. Minerva Alcorta.

Plaintiff’s father,Garry, has a $130,000 life insurance policy under which Alcorta was named the primary beneficiary and Garrett and Aneila were secondary beneficiaries of 50% each of the policy.

Alcorta was charged with intentional first degree murder of Garry.

The 5th Circuit Court of Appeals issued an opinion on January 31, 2019, in a case that is governed by the ERISA.  The opinion is styled, Karen A. Rittinger v. Healthy Alliance Life Insurance Company.

Here, the beneficiary of a health plan governed by ERISA brought action against the plan administrator challenging the denial of coverage for her bariatric surgery and the follow-up surgery required after she developed complications.  This Court ruled in favor of the plan administrator, ruling the administrator did not abuse its discretion when it treated e-mail from the plan beneficiary’s husband as a first-level appeal, and the administrator did not abuse its discretion in denying health plan beneficiary’s second level appeal.

Pursuant to 29 U.S.C.A., Sections 1001 et seq., the Court of Appeals reviews a district court’s grant of summary judgment in an ERISA case de novo.

The Law Office of Mark S. Humphreys, P.C., recently got a surprise for his client when contesting an ERISA life insurance claim.

The insured worked in Louisiana and had a life insurance policy through his employer. The insured was not married and did not have any children. Thus, the insured named his brother’s child as the beneficiary of his life insurance policy. The amount of the policy was $100,000. The insured was killed in a one vehicle accident. A claim was made for benefits. The plan administrator denied the claim benefit based on an exclusion if the deceased died as the result of intoxication. The toxicology report indicated proof of cocaine in the body of the insured at the time of the accident.

Mark hired a toxicology expert to write a report and contested the denial of benefits through the administrative process that has to be followed in ERISA claims. The report pointed out that the amount of cocaine in the system of the deceased was stated as being a “trace” amount. The toxicology expert report pointed out there was no way to prove intoxication had anything to do with the cause of death when the amount is just a “trace.”