Articles Posted in ERISA

In an ERISA case, the plan administrator, upon request, is required to give a copy of the claims file to the insured.  The most common way this occurs is when a claim is denied, the plan administrator informs the insured of the denial in a written letter and in the letter the insured is informed of their right to an appeal and a copy of the claims file.  The insured should then request a copy of that file.

In a recent case out of the Southern District of Texas, Houston Division, the insured claimed they did not timely receive a copy of the claims file and thus, argued that the statute of limitations on their claim was tolled until such time that she received the claims file.  This case is styled, Cynthia Sternberg v. Metlife Insurance Company.

In this case, the insured has clearly let the statute of limitations pass for her appeal.  These limitations were made clear in the policy.  So, the insured made arguments regarding the tolling of the limitations period.

Statute of Limitations issues are not usually seen in ERISA cases, but here is one.  This is a 2019, opinion from the Southern District of Texas, Houston Division.  It is styled, Cynthia Sternberg v. Metlife Insurance Company.

This case is currently before the Court on a Rule 12(b)(6) Motion to Dismiss filed by Metlife.  The Court granted the motion.

Sternberg filed for short term disability (STD) benefits from her employers claims administrator.  The STD benefits were granted.  Metlife is the claim administrator and it issued the group policy that funds the benefits under the Plan.  Sternberg later, filed for long term disability (LTD) benefits.  The claim for LTD was denied.

ERISA has it’s own set of rules and regulations and is unlike normal insurance that is governed by State laws and the Texas Department of Insurance.

Here is a 2019, opinion from the Eastern District of Texas, Sherman Division, that deals with ERISA and a claim for Long Term Disability (LTD) benefits.  The opinion is styled, Xien Huang Napodano v. Ericsson Inc. Short Term Disability Plan.

On August 22, 2017, Napodano resigned from his job by leaving a note on the desk of his boss and a few days later applied for LTD benefits.  He was informed that he had to first apply for Short Term Disability (STD) benefits first, before being eligible for LTD benefits.  He then filed for STD benefits.

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.

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.