ERISA – A Win!

Insurance attorney who handle denied claims and in particular insurance attorneys who are willing to take on an insurance claim governed by ERISA claim which has been denied, needs to read this opinion from the Eastern District of Texas, Sherman Division.  The case is styled, Gina Pike v. Hartford Life And Accident Insurance Company.

Pike had received long term disability (LTD) benefits from Hartford from April 24, 2008 through December 14, 2016, the period of time when Hartford determined Pike met the definition of disability in the LTD policy.  Later, after determining Pike was unable to prove she continued to be disabled under the policy, the benefits ceased on December 15, 2016.

This case resulted in a 51 page opinion which is not going to be discussed at any length here.  What is relevant is that it is rare for beneficiaries of these employer sponsored benefit plans and as a result needs to be carefully read to determine what the Court saw that separated this case from other ERISA cases.

The parties elected to proceed pursuant to Federal Rule of Civil Procedure 52, which requires the court to set out its finding on all factual questions that arise in a case.  This is an indication that both parties intended to file an appeal based on which side had the ruling go against them.  Thus, it is likely we will see more of this case after an appeal to the 5th Circuit Court of Appeals.

The portion of the opinion found on page 13 of the opinion is noteworthy.  This case was originally heard by the Magistrate and then appealed to the District Court Judge who essentially confirmed the findings of the Magistrate.  The significant language for lawyers handling these ERISA cases is “but unless information available to an insurer alters in some significant way, the previous payment of benefits is a circumstance that must weigh against the propriety of an insurer’s decision to discontinue those payments.”  In citing this language the Court spent a large of amount of discussion on Pike’s condition and the changes, if any, when the claim was denied.

A must read for ERISA lawyers.