Articles Posted in ERISA

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.

Repeating what was stated in the post immediate to this one, “It is important to understand how difficult claims that are governed by the Employee Retirement Income Security Act (ERISA) can be.  The law in this area of law is very tough for claimants.”  This is illustrated again in a December 2020, opinion styled, Erica Talasek v. Unum Life Insurance Company of America, et al.  The opinion is from the Southern District of Texas, Houston Division.

The insured, Ben Talasek, had life insurance through a Plan his employer, NOV, offered.  NOV delegated authority and discretion to UNUM to handle claims and made benefit determinations.

Ben was covered by basic life insurance coverage and Ben also enrolled in a voluntary supplemental plan during November 2013.  Unlike the basic life insurance, which did not require medical underwriting, the supplemental life insurance required an employee to submit evidence of insurability and obtain approval for coverage by Unum.  On January 18, 2014, Unum sent Ben a letter informing him of an error in his application and the need for additional information.  Around this time, Ben was diagnosed with pancreatic cancer.  Ben called Unum on January 21, 2014 to check on the status of his application and was told about the January 18 letter.  Ben corrected the error on the Evidence of Insurability Form and supplied additional information.  Ben called Unum again on February 12, 2014 to check on the status of the application and was told that the standard turnaround time for a coverage decision was 4-6 weeks.  On March 3, 2014,several weeks after receiving his cancer diagnosis, Ben provided blood and urine samples and basic health history as part of Unum’s requirement that he prove insurability prior to approval of coverage.  He did not mention the cancer diagnosis.

The Employee Retirement Income Security Act (ERISA) is a confusing area of law for most people who have those type of policies and it is also confusing for attorneys.  An opinion dealing with the time periods for filing a life insurance claim are discussed at length in a 2021 opinion from the Western District of Texas, Austin Division.  The opinion is styled, Dusty Bauer and Allan Agababa v. National Union Fire Insurance Company of Pittsburg, PA and AIG Claims, Inc.

This lawsuit is concerning accidental death benefits owed upon the death of Shelly Bernstein (Decedent).

The Decedent had an accidental death benefit policy through his employer which was funded by National and AIG.  The policy limited conditions under which the death benefits would be paid by providing contractual limitations periods.  Some of those limitations periods read as follows:

Here is a somewhat lengthy opinion in a case involving the Employee Retirement Income Security Act (ERISA) and a disability claim.  The opinion is from the Western District of Texas, Austin Division, and is styled, Jason Thomas Young v. Reliance Standard Life Insurance Company and Matrix Absence Management, Inc.

Plaintiff, Young, was insured by way of an ERISA disability plan through his employer when he was injured in an automobile accident.  He applied for and received disability benefits.  At a later date is recovered a substantial settlement from the insurance company of the person with whom he had the accident.  The disability plan administrator then attempted to offset the monies Young received from payments Young was receiving for disability pay.

Young filed suit and the plan administrator rescinded their earlier decision to offset payments.  After agreeing to make regular payments for disability without taking into account any offsets, the plan administrator filed a Rule 12(b)(1) and Rule 12(b)(6) motions to dismiss Young’s claim based on the assertion that the matter was now moot and that Young has no standing to continue the lawsuit.

This post is a continuation of Parts 1, 2, and 3, posted earlier.  This case involves a life insurance policy claim denial that is governed by the Employee Retirement Income Security Act (ERISA).

The opinion is from the Southern District of Texas, Houston Division, and is styled, Erica Talasek v. Unum Life Insurance Company of America, et al.

As in most ERISA claims, the case is being decided on competing Motions for Summary Judgement.  The Court found in favor of Unum and explained it’s finding in detail.

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