ERISA

Insurance Claim Denial Attorney – ERISA

December 26, 2020 | Mark S. Humphreys

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.

Life Insurance – ERISA – Alcohol

November 2, 2020 | Mark S. Humphreys

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.

ERISA – Long Term Disability Benefits

October 26, 2020 | Mark S. Humphreys

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.

ERISA – State Law Versus Federal Law

October 19, 2020 | Mark S. Humphreys

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.

Life Insurance And ERISA

July 22, 2020 | Mark S. Humphreys

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.

ERISA And How It Works

May 16, 2020 | Mark S. Humphreys

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.

Life Insurance Case And ERISA

April 12, 2020 | Mark S. Humphreys

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.”

ERISA Clain Or Not?

March 25, 2020 | Mark S. Humphreys

ERISA stands for Employee Retirement Income Security Act. When making an insurance claim related to employment, it is important to know it the claim is subject to ERISA, which is governed by Federal Law, or not ERISA, in which case the claim is governed by State Law.

Plus, there are employee benefit plans that would be governed by ERISA however, elements of the employee benefit plan may fall outside of ERISA. This is discussed in a 2020 opinion from the Western District of Texas, Austin Division. The opinion is styled, Stephen Burrell v. Metropolitan Life Insurance Company and Deloitte LLP.

Burrell’s lawsuit was for short term disability (STD) benefits that had been denied and for long term benefits (LTD) that had been denied. This discussion will focus on the STD benefits claim.

ERISA – Life Insurance

January 19, 2020 | Mark S. Humphreys

Employee Retirement Income Security Act (ERISA). These cases are tough even under the best of circumstances. Lawyers who handle ERISA cases do not spend time advertising their great results. The reason is the ERISA law prohibits “great” results. A win is just getting what you should have received in the first place. But wins are few and far between, especially in the United States Fifth Circuit.

Here is a case from the Northern District of Texas, Wichita Falls Division. It’s styled is, Edythe Koch v. Metropolitan Life Insurance Company.

In this case, the Court denied MetLife’s motion for summary judgment which is unusual in these cases, thus, at first blush one thinks a win is coming. But when the Judge conducted it’s own review of the record, the Court upheld the plan administrator’s denial of accidental life insurance benefits.

Life Insurance Claim And ERISA

November 17, 2019 | Mark S. Humphreys

Many employer based insurance plans fall under ERISA. Understanding how the courts look at ERISA cases is important for life insurance lawyers to be able to discuss a case with a client.

The United States Court of Appeals for the Fifth Circuit recently ruled on a case that involved a life insurance policy that was governed by ERISA. The styled of the case is Jason Freeman v. Securian Life Insurance Company.

Jason Freeman was the father of 17 year old Adrian. Adrian died instantly when he pulled the trigger of a revolver, the barrel of which he had inserted in his mouth immediately after he had spun the gun’s cylinder and twirled the gun around his finger. Soon after the death of Adrian, it was determined that the revolver had only one cartridge in the cylinder. The conclusion by the Deputy Medical Examiner of Bexar County, Texas, was that Adrian’s death was the result of a suicide.