Articles Posted in ERISA

Here is a case wherein one of the issues was whether or not an employee was eligible for Long Term Disability (LTD) based on the definition in the policy of “full time” employee.

This is a 2022, case is from the 5th Circuit Court of Appeals. It is an appeal from the Northern District of Texas.  The opinion in the case is styled, James W. Newsom v. Reliance Standard Life Insurance Company.

Newsome had a policy that, among other things, provided short term disability (STD) benefits and LTD benefits.  The plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA).

Here is an opinion from the United States 5th Circuit dealing with ERISA.  This particular case discusses the Employee Retirement Income Security Act of 1974 (ERISA).  While the case is not a life insurance case, the ruling would also apply to life insurance situations.  The style of the case is Ramirez v. Inter-Continental Hotels.

Ramirez had filed suit in State Court, asserting various contract, tort, and statutory causes of action against his former employer and its insurance carrier, Travelers.  The Defendants removed the case to federal court, asserting ERISA.

Ramirez concedes, this lawsuit is essentially one to recover benefits from an ERISA plan.  As such, it comes within the scope of ERISA’s civil enforcement provision, Section 502(a)(1)(B), 29 U.S.C. Section 1132(a)(1)(B), which allows a civil action to be brought (1) by a participant or beneficiary (B) to recover benefits due to him under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.

The Employee Retirement Income Security Act of 1974 (ERISA) applies to a lot of employer benefit plans.  Each of these cases need to be examined by looking at the wording of the plan and the facts of the case.

A 2021 opinion from the Northern District of Texas, Dallas Division, is a good opinion to look at when there is a cause of action for Promissory Estoppel.  The style of the case is, Medarc, LLC vs. Meritain Health, Inc.

Promissory Estoppel is the legal principle that a promise is enforceable by law, even if made without formal consideration when a promisor has made a promise to a promisee who then relies on that promise to his subsequent detriment.

ERISA stands for Employee Retirement Income Security Act of 1974.  The way ERISA cases are handled is unique from a legal perspective.  This is illustrated in a 2021, opinion from the Eastern District of Texas, Sherman Division.  The opinion is styled, Carol Sue Allen, Et Al. v. Sherman Operating Company, LLC.

This is an appeal from a Magistrate’s summary judgment ruling in favor of Sherman.

Allen was injured at work.  She made a claim for disability benefits under a plan provided by her employer, which is an ERISA plan.  Her claim for benefits was denied by the plan administrator.  She filed suit alleging various causes of action.  The cause of action discussed here has to do with her assertion there were violations of the ERISA plan.  She claims the plan administrator abused its discretion when her clam for benefits.

Lawyers who handle long-term disability (LTD) claims that are governed by the Employee Retirement Income Security Act of 1974 (ERISA), will want to read this opinion.  The opinion is titled, Enrique Talamantes v. Metropolitan Life Insurance Company.  It is a 2021, opinion from the United States Fifth Circuit.  It is a ruling that is favorable to the insured, which is unusual in cases governed by ERISA.

Plaintiff, was an engineer for him employer, BD.  BD provided its employees LTD coverage through plans governed by ERISADuring the relevant time period, BD used two insurers, Standard Insurance Co. (“Standard”) for the 2016 calendar year and MetLife Insurance Co. (“MetLife”) for the 2017 calendar year, to fund LTD payments under the Plan.

On November 9, 2016, Plaintiff became disabled due to trigeminal neuralgia and underwent microvascular decompression surgery.  In light of this disability, Plaintiff was approved for and paid short-term disability(“STD”) benefits for 34 days under the Plan from November 18, 2016 through December 22, 2016.  The Plan’s STD benefits were paid by BD and administered by Sedgwick Claims Management Services (“Sedgwick”) and did not involve Standard or MetLife.  On December 23, 2016, Plaintiff returned to full-time active work.  Standard’s policy terminated on December 31, 2016, and MetLife’s policy became effective on January 1, 2017. On January 12, 2017, Plaintiff stopped working and again became disabled because  of a relapse in his trigeminal neuralgia symptoms.

Life insurance denials are much more common than people realize.  Most people would be of the opinion that once a person had paid for life insurance and then a death occurs, that the policy would pay.  That is not the case.

Here is an opinion from the Southern District of Texas, Houston Division.  It is styled, Sydney Joe Gray v. Minnesota Life Insurance Company.  This case involves an accidental death policy that is governed by the Employee Retirement Income Security Act of 1974 (ERISA).

The lawsuit is brought under 29 U.S.C., Section 1132(a)(1)(B).  The deceased, Michael Gray had an accidental death policy he obtained through his employment.  Sydney Gray is the beneficiary of the policy.

Life Insurance lawyers often see disputes over who is entitled to life insurance proceeds.

A 2021, opinion from the Southern District of Texas, Houston Division, is a dispute over who is entitled to life insurance proceeds.  Also, the life insurance policy at issue in this case is governed by the Employee Retirement Income Security Act of 1974, (ERISA).  The opinion is styled, Christine and Denise Morgan v. Prudential Life Insurance – Prudential Life Insurance v. Linda Arriazola and Elvia Barrera.

This case was decided on competing motions for summary judgment.

The Employee Retirement Income Security Act of 1974, (ERISA) applies to a majority of employer provided insurance plans.  These plans include, life, disability, and health.  What is important to understand about ERISA plans is that it is rare in the extreme that a court will over-turn a decision by an ERISA plan administrator.  This is seen again in a 2021 opinion from the Western District of Texas, Austin Division, styled, Marc Worob, individually and as next friend of M.W. v. Blue Cross And Blue Shield Of Texas, A Division Of Health Care Service Corporation.

This case is decided in favor of the insurance company plan administrator on competing motions for summary judgment.

The Plan provides coverage for five categories of Eligible Expenses: (1) Inpatient Hospital Expenses; (2) MedicalSurgical Expenses; (3) Extended Care Expenses; (4) special provisions expenses; and (5) pharmacy expenses.  The first category, Inpatient Hospital Expenses, includes “Medically Necessary services for Serious Mental Illness in a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, a Residential Treatment Center for Children and Adolescents, or a Residential Treatment Center in lieu of hospitalization.”  The Plan defines a Residential Treatment Center as a:

Long Term Disability (LTD) claims are not uncommon in the insurance world.  Some of these claims are easy to see and understand, such as an amputation.  Other LTD claims are less easy to see and understand, such as chronic conditions and conditions that do not show up easily on tests and can be very subjective.  It is the other type of LTD claims that end up being denied by insurance companies.

While many denied claims can be contested by hiring an insurance lawyer, many are complicated legal battles.  What makes too many of these LTD claims even harder to contest if denied, is when the plan is through a person’s employer and governed by the Employee Retirement Income Security Act (ERISA).

A 2021 opinion from the Southern District of Texas, Houston Division, deals with an LTD claim that is governed by ERISA.  The opinion is styled, Mark Calkin v. United States Life Insurance Company In The City Of New York.

Life insurance lawyers will have situations where a person has died and the issue is whether or not the death was an “accidental death” and did any exclusion apply to the accidental death.

Here is a 2021, opinion that deals with an accidental death policy with an exclusion and on top of that, the policy is governed by the Employee Retirement Income Security Act (ERISA).  The opinion is from the United States Court of Appeals, 5th Circuit.  It is styled, Luis Lebron v. National Union Fire Insurance Company of Pittsburgh, Pennsylvania; AIG Claim, Incorporated.

Luis had an accidental death policy he purchased through his employer that insured himself and his wife, Barbara.  The policy was issued by National Union and contained an exclusion for death caused “in whole or in part” by “illness, sickness, disease, bodily or mental infirmity, medical or surgical treatment (unless treating a covered injury), or bacterial or viral infection, regardless of how contracted (except when bacterial infection results from an accidental cut or wound or accidental food poisoning).”  Under this ERISA plan National Union had authority to determine benefit eligibility as the plan administrator.

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