Articles Posted in ERISA

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.

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 of 1974 (ERISA) offers many of the same types of insurance coverage for individuals as other plans.  The distinctions with ERISA is that the plan is a plan for employers to offer to employees that is set and governed by Federal Law rather than State Law.

ERISA plans offer retirement programs, life insurance, disability insurance, and health insurance.  The Southern District of Texas, Houston Division, issued an opinion in November 2020, on a case that is governed by ERISA.  The opinion is styled, Wagna Mina huerta v. Shell Oil Company and Shell Oil Comprehensive Welfare Benefits Plan.

This case discussed a couple of issues.  One of those, rarely seen in an opinion, is discussed here.

The Employee Retirement Income Security Act (ERISA) provides various kinds of insurance to employees.  The important thing for insurance lawyers to know about ERISA is that it is governed by Federal law and it preempts State law.  This is illustrated in a 2020, opinion from the Western District of Texas, San Antonio Division.  The opinion is styled, Marco Z. v. UnitedHealthcare Insurance Company, Forma Automotive, LLC.

Marco does not dispute that the health plan at issue is governed by the ERISA.  Further, it is undisputed that at the time of the incident forming the basis of this action Marco was a beneficiary of the subject ERISA health plan established and maintained by Forma Automotive and administered by UnitedHealthcare.

Marco sustained medical problems in Mexico and was forced to seek medical assistance.  Marco  assigned insurance benefits to the Hospital, which is not a network provider under the Plan.  As a non-network provider, it has no express contract with UnitedHealthcare establishing payment for medical services provided to beneficiaries of the Plan.

Here is a life insurance case which is governed by the Employee Retirement Income Security Act (ERISA).  The opinion is from the Southern District of Texas, Houston Division.  It is styled, Heidi Ballard v. Lincoln Life Assurance Company of Boston.

The deceased had an accidental death life insurance policy which was governed by ERISA.  The death resulted when the deceased, riding as a passenger in a golf cart, was thrown out of the car after the driver of the cart suddenly and unexpectedly accelerated the cart.  This was witnessed by others.

Lincoln Life denied the claim based on an exclusion in the policy excluding an accidental death that is the result of consuming alcohol.

Here is a case worthy of all attorneys handling Employee Retirement Income Security Act (ERISA) cases should read and take note about.  The opinion is from the Northern District of Texas, Dallas Division.  It is styled, James W. Newsom v. Reliance Standard Life Ins. Co.

The most noteworthy aspect of this case is that it is a win for the employee.  A win for an employee in an ERISA case is extremely rare.

The Facts of the case are somewhat complicated and convoluted.  The focus here will be the Court’s interpretation of the policy language.

Here is an opinion for lawyers handling Employee Retirement Income Security Act (ERISA) cases.  The opinion is a 2020, opinion from the Southern District of Texas, Houston Division, and is styled, Kimberly Holick v. Aetna Life Insurance Company.

Holick was an employee of Parkway Chevrolet and covered under its Aetna issued group insurance policy.  After an alleged injury, Holick’s doctor ordered an MRI and Aetna denied coverage.  Aetna later reversed its decison and Holick eventually received the MRI.

Holick claims Aetna wrongfully denied her treatment and failed to timely reverse its denial of coverage and the delay prevented timely repair and caused her pain and deformities.

Here is a case arising out of the Employee Retirement Income Security Act (ERISA) which involves life insurance.  The case is from the Northern District of Texas, Lubbock Division.  It is styled, Elizabeth Hernandez v. Unum Group v. Sara Hernandez and Jose Hernandez.

The basic Facts are that Xavier Hernandez had a policy of live insurance with his employer that was part of an ERISA plan.  On May 24, 2018, Xavier was killed in an auto accident.

From August 2015, until May 2018, Xavier was married to Sara Hemandez.  In January 2018, Xavier designated Sara as the beneficiary of his life insurance policy.  Weeks before Xavier’s death, he and Sara divorced.  The divorce decree indicates that both Sara and Xavier were present at the proceeding and does not mention Xavier’s life insurance policy.  Sara represents that, at the time of the divorce, she was unaware that she was the beneficiary under Xavier,s policy and only became aware once Xavier’s employer advised her of her status.  She maintains that she did not waive her rights as a beneficiary under the policy in the divorce decree or elsewhere.

Attorneys who handle Employee Retirement Income Security Act (ERISA) cases need to be able to explain to potential clients how ERISA cases are handled / looked at, by the Courts.  This is explained in a 2020 opinion from the Western District, San Antonio Division, case.  The case is styled, Ramon Hernandez v. Life Insurance Company of North America, Schlumberger Group Welfare Benefits Plan.

The case needs to be read to grasp an understanding of the underlying facts.  Here, we are looking at the law the Court used in reaching its determination.

In this case, the Court granted summary judgment against Hernandez.  In reaching the decision, the Court restated law as it relates to ERISA cases.  The Court looks at these cases under an “abuse of discretion” standard, not a de novo standard.

Here is a 2020, case from the Southern District of Texas, Houston Division, that deals with life insurance wherein the life insurance plan is subject to the Employee Retirement Income Security Act (ERISA). The case is styled, Wagma Mina Huerta v. Metropolitan Life Insurance Company, et al.

This case, filed by Huerta , is an action pursuant to ERISA seeking equitable relief for alleged breaches of fiduciary duty by the Defendants related to the denial of life insurance coverage for the death of Huerta’s husband.

The opinion is lengthy but only a part will be discussed here.  The factual background can be read in the opinion.  In this case, MetLife had filed a motion to dismiss pursuant to Federal Rule 12(b)(6), which allows dismissal of an action whenever the complaint, on its face, fails to state a claim upon which relief can be granted.  United States, 5th Circuit case law states that when considering a motion to dismiss, the court may consider, in addition to the complaint itself, “any documents attached to the motion to dismiss that are central to the claim and referenced by the complaint.”  This is discussed in the 2010, opinion, Lone Star Fund V (U.S.), L.P. v. Barclays Bank PLC.  When a defendant attaches such documents, it “merely assists the plaintiff in establishing the basis of the suit and the court in making the elementary determination of whether a claim has been stated.”

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