by Cody AllisonAvenoso v. Reliance Std. Life Ins. Co.
In an ERISA long term disability case, the district court’s entry of summary judgment in favor of a claimant was affirmed because, while the court adjudicated the parties’ summary judgment motions as if it were ruling in a bench trial, whether the district court’s decision survived de novo review of its legal determinations and clear error review of its factual findings turned on whether it clearly erred in finding the claimant lacked sedentary work capacity on the record before it, the appellate court could not say the district court’s finding that the claimant lacked sedentary work capacity was clearly erroneous, and it had to disregard as harmless the district court’s error in adjudicating the parties’ motions for summary judgment as if it were ruling in a bench trial.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonMarcin v. Reliance Std. Life Ins. Co.
In a challenge to the denial of benefits, the district court properly awarded ERISA benefits on the basis that the Plaintiff proved partial disability. According to the express terms of the long term disability plan, partial disability was the equivalent to total disability, and the Plaintiff was totally disabled with the relevant period. Because the Plaintiff proved partial disability, the plan administrator acted unreasonably in denying her benefits. The Court affirmed the lower court’s judgment determining that the Plaintiff was entitled to benefits, and the amount of benefits owed.
As we have said over and over in this blog, the policy controls. Here, the plan allowed the Plaintiff to merely prove partial disability to be considered totally disabled. The Court enforced this provision, as it should have.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonCollier v. Lincoln Life Assurance Company of Boston
Previously in this blog, we have examined what the duties and responsibilities of a claimant in the review of a claim, and what are the duties and responsibilities of a Plan Administrator. This case deals with the duties and responsibilities of the court in these reviews.
In this case, the U.S. Court of Appeals reversed the district court’s judgment in favor of the Defnedant and remanded the case in an ERISA action brought by the Plaintiff.
The Plaintiff challenged the Defendant’s denial of her claim for long-term disability benefits. On de novo review, the district court affirmed the Defendant’s denial, but it adopted new rationales that the ERISA plan administrator did not rely on during the administrative process. Specifically, the district court found for the first time that the Plaintiff was not credible and that she failed to supply objective evidence to support the claim.
The Court held that when a district court reviews de novo a plan administrator’s denial of benefits, it examines the administrative record without deference to the administrator’s conclusions to determine whether the administrator erred in denying benefits. The district court’s task is to determine whether the plan administrator’s decision is supported by the record, not to engage in a new determination of whether the claimant is disabled. Accordingly, the district court must examine only the rationales the plan administrator relied on in denying benefits and cannot adopt new rationales that the claimant had no opportunity to respond to during the administrative process.
The Court held that the district court erred because it relied on new rationales to affirm the denial of benefits. As Defendant did not present these rationales during the administrative process, Plaintiff was afforded no opportunity to respond to them, and was denied her statutory right to “full and fair review” of the denial of her claim. The Court reversed and remanded the case to the district court to reconsider the Plaintiff’s claim de novo, with no deference to the administrator’s decision, and to determine whether the record evidence supports the reasons on which the Defendant relied to deny benefits.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonRushing v. Sun Life Assurance Co of Canada
This is an unusual case under ERISA.
Matthew Rushing died as a result of an auto accident. His wife, Katie Rushing (“Plaintiff”), filed a claim for benefits under an Accidental Death and Dismemberment Policy in which the Rushings participated as part of an employee benefits plan issued through Katie’s employer. Sun Life Assurance Company of Canada (“Sun Life”) is the insurer and administrator of the policy.
Sun Life denied the claim on the grounds that Mr. Rushing’s death did not meet the definition of an accident under the policy. Plaintiff filed this civil action to challenge that decision under the applicable ERISA standard of review. Sun Life, after suit was filed, communicated to Plaintiff that the results of Mr. Rushing’s toxicology report also provided grounds for denial of the claim. Sun Life filed a Motion to Stay and to Remand for Administrative Review that is now before the court. Sun Life urges that its new basis for denying the claim was not thoroughly evaluated during the administrative review process so is not ripe for a judicial determination. Plaintiff responds that Sun Life conducted the administrative review process with the toxicology report in hand, and it should not now be allowed a second round of administrative proceedings to urge a defense that it could have asserted the first time. For the reasons that follow, Sun Life’s motion will be denied….
Sun Life[’s] … reasoning was that the car suddenly crossed the center line with no known reason such as weather or mechanical problems. Plaintiff had a full and fair opportunity to challenge that reasoning during the administrative process. After the case arrived in court, Sun Life sought for the first time to point to other evidence, in the form of the toxicology report and its belief about the effect of the level of substances in Matthew’s system, as a new basis for its decision that Matthew’s death was not caused by an accident. The record indicates that Sun Life was in possession of the toxicology report early in the administrative process .…
Remand may be appropriate to provide a remedy to a claimant who has been denied a full and fair opportunity to address an issue during the administrative process, but it is not appropriate for the plan or insurer to wait until a case is in federal court and then seek remand to build a new basis for denial that it reasonably could have developed during the administrative process. Sun Life … should not now be allowed to further delay the proceedings to go back and attempt to improve its position. For these reasons, the court finds that the best exercise of its discretion in these circumstances is to deny a remand and proceed with having the parties stipulate to the contents of the administrative record and briefing the merits. Accordingly, Sun Life’s Motion … is denied.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonMcQuillin v. Hartford Life and Accident Insurance Company
This ERISA case has not been decided yet but makes an interesting argument. This is an “Amicus Curiae” (friend of the court) brief submitted by the U.S. Secretary of Labor.
The Plaintiff/Insure had received unsuccessful treatment for prostate cancer, which had left him him with a long list of medical problems. He filed a claim for long term disability with the Defendant. This claim was denied, stating that the Plaintiff had not provided enough information to show that he was unable to work. Plaintiff had 180 days to appeal this decision and sought two extensions within which to appeal. The Defendant denied the first extension and did not respond to the second, so the Plaintiff timely appealed. The Defendant then notified the Plaintiff that it had reversed its original denial but stated that this reversal did not guarantee payment of benefits. The Defendant stated that the claim department would review the submitted information and determine if the Plaintiff met the definition of disability and then render a new decision. The Defendant did not state when this would be done. The Plaintiff waited 46 days, and then filed suit under ERISA. Finally, months later, the Defendant notified the Plaintiff that it had denied his long term disability claim again. The district court dismissed the Plaintiff’s claim because it determined that the Plaintiff had not exhausted all his remedies administratively with the Defendant before resorting to the courts.
The Plaintiff argues that the Claims Procedure Regulation sets for the minimum requirements for the employee benefit plan procedures pertaining to claims for benefits. This procedure requires ERISA plans to decide benefit appeals within specified time frames. If the Defendant fails to meet these time frames, the Plaintiff is deemed to have exhausted administrative remedies and is entitled to pursue any available remedies under ERISA. The district court in this case held that the Defendant timely issued a benefit determination on review by sending the claim to its claim department. The Plaintiff argues that this is contrary to the plain language, structure and purpose of the claims-procedure regulation. The Plaintiff argues that a “benefit determination on review” requires a straight up or down decision either granting or denying benefits. The Defendant’s sending the claim to its claim department ending nothing. Further, the Plaintiff argues that the idea that plans can simply “remand” benefit appeals back to themselves without deciding whether benefits are due undermines ERISA’s goal of ensuring speedy decisions. If a “remand” qualifies as a “benefit determination on review” under ERISA, a defendant plan could repeatedly issue vacate-and-remand decisions, endlessly, without contradicting the regulations.
The U.S. Secretary of Labor issued an Amicus Curiae brief supporting the Plaintiff’s argument. It reviewed the applicable statues under ERISA for plain language and agreed with the Plaintiff’s assertions. The Secretary ends its brief by requesting that the Court reverse the lower court’s dismissal of the Plaintiff’s claims. Stay tuned for the result.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonFibromyalgia and Long-Term Disability
The link below carries you to a NOLO article regarding the intersection of fibromyalgia and LTD claims. The article makes the very important point that many insurance companies almost automatically deny claims related to this debilitating disease and that it may be necessary to bring in an experienced attorney to handle a long-term disability claim based on fibromyalgia. Here at Cody Allison and Associates, we have experience with these kinds of claims and we stand ready to help you recover the benefits that are due to you. Contact us today!
http://www.nolo.com/legal-encyclopedia/long-term-disability-benefits-fibromyalgia.html
by Cody AllisonKennedy v. Lilly Extended Disability Plan, ERISA and Long Term Disability
This ERISA case, decided in 2017, is a case dealing with the Defendant failing to make a record for the case.
The Plaintiff/Insured was hired by the Defendant and rose rapidly, eventually becoming an executive director in the human resources division. However, after working at the company for over three decades, she was forced to quit because of disabling symptoms of fibromyalgia. She made an initial claim for long term disability benefits which was granted. Three and a half years later, these benefits were terminated. She brought suit. At trial, the Defendant based it’s denial on evidence presented by a number of doctors. However, the Court found that this evidence was a hodge-podge and was not consistent. However, the Court also found that even if this evidence was not deficient, the Defendant failed to indicate what job or kind of job, and on what level, the Plaintiff would be capable of performing if it was permitted to cancel her benefit. Further, the Court found that the evidence submitted by the Plaintiff’s treating rheumatologist demonstrated that the Plaintiff had flare-ups of her condition periodically and that the Plaintiff would not be able to work any sort of regular schedule because of this. The Court found that the Defendant did not demonstrate that this doctor’s opinion was incorrect. Therefore, the judgment of the lower court, granting the Plaintiff back due and ongoing long term disability benefits was affirmed.
If the employer wants to deny the benefits under ERISA, it better have its ducks in a row. Here, the employer did not. It is clear from the opinion that the employer presented a sloppy case, and the denial of benefits was arbitrary and capricious. The Court didn’t let it stand and the employee was justly compensated.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonCheney v. Std. Ins. Co., ERISA and Long Term Disability
This ERISA case, decided in 2018, is a case dealing with the limits on the ability of the court to “do what is right” rather than what the long term disability policy requires.
The Plaintiff/Insured was an attorney who had been with her firm for about 20 years and eventually became a partner. She began to suffer from a spinal disease that eventually lead to her having a three-level anterior cervical discectomy and fusion and removal of her C5 vertebra. She eventually was unable to work and submitted a long term disability claim, which was denied based on the fact that her coverage ended in December of the year before she stopped working. She brought an action before the district court. The district ruled in her favor and the Defendant appealed. The Court found that the district court, in reaching its decision, ignored certain policy provisions and made conclusions of fact without supporting evidence. A new trial was necessary because the district court failed to find when the Plaintiff had become disabled, to use as a basis of comparison all work that some licensed to practice law in Illinois may have performed, and to analyze the medical evidence in the proper light. The district court’s calculation of predisability earnings based on the last full year that the Plaintiff worked was not tenable because the Plaintiff made the consistent claim of December 20, 2011 as the date of the date of the beginning of her disability and then worked beyond that date. The Court found that the district court erred in interpreting the long term disability policy and made factual findings unsupported by the record evidence. Therefore, the district court’s judgment was vacated and the case was remanded for a new trial.
In previous blogs, we have examined the duties and responsibilities of both the Plaintiff and the Defendant in ERISA long term disability cases. Here, we have an example of the duty of the court in these cases. The district court overreached in what it did in its decision here, and it was quickly and decisively put back in line by the appellate court in a decision that was probably somewhat embarrassing for the lower court. Even the Courts are bound by the terms of the long term disability plans in these cases.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonLeger v. Tribune Co. Long Term Disability Benefit Plan, ERISA and Long Term Disability
This ERISA case, decided in 2008, is a case dealing with the arbitrary and capricious standard for reviewing the decisions of the plan administrator.
The Plaintiff/Insured began receiving long term disability benefits in 1990 due to debilitating osteoarthritis in both knees. In 2005, the plan terminated her benefits and the claimant filed this action. The district court concluded that the plan’s decision was not arbitrary and capricious and granted summary judgment in its favor. On review, the Plaintiff argued that a different standard of review was required after a decision in the Glenn case by the Supreme Court. However, the Court rejected that argument, finding that the arbitrary and capricious standard was still applicable with any conflict of interest taken into account as a factor. While the Court rejected the Plaintiff’s argument that previous payment of benefits and a decision at odds with an opinion of a treating physician created a presumption that the termination decision was arbitrary and capricious, it did agree with the Plaintiff that the long term disability plan failed to consider the Plaintiff’s complete medical history and then rejected, without explanation, important aspects of the Functional Capacity Evaluation. As a result, the plan acted in an arbitrary and capricious manner in terminating benefits and a remand was necessary.
Here, the Court found no merit in the Plaintiff’s main argument, but did find that the lower court erred in the arbitrary and capricious determination. This case is a good example of the importance of exhausting all appeals before giving up on a case.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonNewsom v. Reliance Std. Life Ins. Co., ERISA and Long Term Disability
This ERISA case, decided in 2022, is a case dealing with the definitions of terms contained within the long term disability policy.
The Plaintiff/Insured had been employed as a software architect for 23 years. He had health problems dating back several years, including chronic fatigue syndrome, fibromyalgia, depression and attention deficit hyperactivity disorder. His health eventually deteriorated to the point that the could no longer work a 40 hour week. The employer reduced his scheduled work week to 32 hours, which it still considered to be full time. However, eventually the Plaintiff went to part time, working less that 30 hours per week. Finally, the Plaintiff became unable to work at all, and made an initial claim for short term disability benefits. In that claim, it was the Plaintiff’s doctor’s opinion that he would eventually be able to return to work in a few months. The Employer indicated that the Plaintiff had only been working part time before he stopped working, and the Defendant initially denied the claim based on the fact that the Plaintiff was not a full time active employee and did not qualify for coverage under the terms of the plan. The Plaintiff appealed this denial contending that the Defendant had incorrectly determined his date of disability under the terms of the plan. The Defendant agreed with this and paid the short term disability benefits at the 26 week maximum period. The Plaintiff also applied for long term disability benefits but the Defendant denied this for the same reasons the short term disability benefits were initially denied. Plaintiff appealed this denial, but the Defendant refused to reverse this decision. The Plaintiff then filed the court action. The district court agreed with the Plaintiff that he should be entitled to the long term disability benefits under the plan. The district court then determined the Plaintiff’s date of disability to be what the Plaintiff alleged that it was under the terms of the plan. The Defendant appealed. The Court found that the district court did not err in determining that the Plaintiff was qualified to receive long term disability benefits because he was a full time employee under the terms of the plan. The Court determined that some of the language of the plan was ambiguous and construed the ambiguity in favor of the Plaintiff. The Court also found that the district court did not err in its determination of the Plaintiff’s disability date based on the terms of the plan. However, the Court did find that the case should be remanded back to the Defendant for determination of the merits claim of the disability award, as opposed to the determination of the plan terms, which had been the subject of this suit. The Court agreed that, under the terms of the plan, this is required. Therefore, the Court remanded the case back to the Defendant to determine if the Plaintiff is entitled to long term disability payments according to the medical opinions of the doctors.
This case is example of the Court clearing the road of the “technical” issues of whether or not long term disability can be awarded, in this case an interpretation of what a full time employee is under the policy, and then allowing the Defendant to determine if the medical proof supports the long term disability award. Presumably, if the Plaintiff disagrees with the Defendant’s determination after consideration of the doctors’ opinions of his disability, he can once again bring the matter to court for a review of the Defendant’s determination.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.