by Cody AllisonEvans v. UNUMProvident Corp.
This ERISA case, decided in 2005 , is another case examining the “arbitrary and capricious” standard that the Court must use in reviewing most of these cases from the lower Court.
In this case, the Plaintiff/Insured worked as a nursing home administrator. She began to suffer from complex intractable seizures. Plaintiff applied for long term disability benefits under ERISA, which were initially granted and then terminated by the Defendant. The Plaintiff filed suit seeking damages resulting from this termination and for reinstatement of her long term disability benefits. The district court granted judgement in favor of the Plaintiff, and the Defendant appealed.
The lower court held that the Defendant had acted arbitrarily and capriciously in terminating the Plaintiff’s long term disability benefits because the Defendant failed to provide a reasoned explanation, based on both the record in the case and express language of the long term disability policy, for terminating the long term disability benefits. The Court found that the Defendant’s decision to rely solely on file reviews by its in-house physicians was questionable in light of the critical credibility determinations made in those file reviews, the factual inaccuracies contained therein regarding the Plaintiff’s treatment history, and the fact that the file reviews categorically dismissed the reliable opinion of the Plaintiff’s treating physician that the stress factor militated against the Plaintiff’s return to work at her administrative position. The lower court was affirmed.
As in the previous cases we have blogged about, the “arbitrary and capricious” standard is difficult to overcome but not impossible. An insurer must act in a measured and reasoned way, and set forth independent reasons for the long term disability benefit termination, or it may not withstand scrutiny by the courts.
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 AllisonRochow v. Life Ins. Co. of N. Am.
This ERISA case, decided in 2014 , is an interesting case regarding the insurance company’s duties as a fiduciary and what damages a Plaintiff may recover when the insurance company wrongfully withholds long term disability payments it should be paying the Plaintiff.
The case had previously been before the Appeals Court which had affirmed the lower court’s finding that the defendant insurance company had acted arbitrarily and capriciously in denying the Plaintiff’s long term disability benefits under ERISA. Upon remand, the lower court ordered the Defendant to disgorge profits flowing from that wrongful denial of benefits, in the form of interest on the benefits that should have been paid to the Plaintiff. This Court examines the lower court’s ruling and determines that it erred in ordering the Defendant to disgorge the money it made from interest while holding the Plaintiff’s long term disability benefits. The Court examines the relevant statutes under ERISA and determines that those statutes are designed to make the Plaintiff whole, not to punish the Defendant for wrongfully denying something to the Plaintiff, or wrongfully gaining something from that denial. The Court finds that the previous finding that the Defendant acted arbitrarily and capriciously and forcing the Defendant to pay all long term disability benefits due and owing to the Plaintiff made the Plaintiff whole. In addition, the Court found that the Plaintiff had also already been awarded his attorneys’ fees for having to bring this suit, and that prejudgment interest may be awarded on remand. There was no showing by the Plaintiff that these awards were not sufficient to make him whole. Therefore, the Court reverses the lower court’s order that the Defendant has to disgorge these monies from interest.
Even though this case seems a trifle unfair to the Plaintiff, it is easy to see how the Court arrived at its decision. By examining the statutes from the perspective of making the Plaintiff whole, and not from the perspective of punishing the Defendant, the Court’s decision is well reasoned and accurate.
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 AllisonHelfman v. GE Group Life Assur. Co.
This ERISA case, decided in 2009, is another in the line of cases dealing with the “arbitrary and capricious” standard that the Court has to use when ERISA cases where short term and long term disability cases are appealed in most circumstances, and the case also deals with the “safe harbor” exception from ERISA.
In this case, the Plaintiff appealed the finding that his long term disability benefits plan was governed by ERISA and the finding that one insurer’s termination of benefits was not arbitrary or capricious. The Plaintiff alleged that the “safe harbor” provision applied in his case, which exempts from ERISA coverage certain group-type insurance programs. In cases where the safe harbor provision applies, state law governs the case. In order for this provision to apply, the Court states that there are four criteria that must be met: (1) No contributions are made by an employer or employee organization; (2) Participation in the program is completely voluntary for employees or members; (3) The sole functions of the employer or employee organization with respect to the program are, without endorsing the program, to permit the insurer to publicize the program to employees or members to collect premiums through payroll deduction or dues checkoffs and to remit them to the insurer; and (4) The employer or employee organization receives no consideration in the form or cash or otherwise in connection with the program, other than reasonable compensation, excluding any profit, for administrative services actually rendered in connection with payroll deductions or dues checkoffs. In this case, the Court determined that the Plaintiff’s employer had contributed to premiums on behalf of the majority of the employees and therefore the first criterion of the safe harbor exception could not be met, so the Court affirmed the lower court’s decision. The Plaintiff then alleged that the insurer’s decision to conduct only a file review and to not interview his treating physician supported the allegation that the insurer’s determination to terminate long term disability benefits was arbitrary and capricious. The Court notes that some of the Plaintiff’s claim is based on job stress that is having health effects. The Court determined that the insurer’s thoroughness with regard to the Plaintiff’s stress was to be questioned, based on the disregard of the treating physician’s admonition that the Plaintiff not work, and that the dismissal of the Plaintiff’s claims by the insurer was purely subjective and not relevant. Therefore, the Court affirmed the lower court finding that ERISA governed the Plaintiff’s long term disability benefit plan, but reversed the lower court finding that the insurer’s termination of the Plaintiff’s long term disability benefits under ERISA was not arbitrary and capricious and remanded the case back to the lower court for further proceedings.
Once again, in ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions.
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 AllisonElliott v. Metro. Life Ins. Co.
In this ERISA case, decided in 2006, the question before the Court is whether a long term disability plan administrator acted arbitrarily and capriciously in denying the claimant/Plaintiff’s long term disability benefits under ERISA.
This case is another examining the employer’s duty to not be “arbitrary and capricious” in it’s determination of whether or not a Plaintiff is entitled to long term disability benefits under ERISA. In this case, the Plaintiff had been severely injured in car accident and she began experiencing renewed pain. Her doctors could not explain why her pain had reemerged. She applied for long term disability benefits, which was denied by the administrator of her plan. The Plaintiff appealed the denial and the administrator hired a physician to review the file. This physician, after only a file review, concluded that the Plaintiff’s condition had improved and that she was capable of performing sedentary work. Based on this, the administrator continued to deny benefits. The Plaintiff took the matter to the district court in Kentucky, who found in favor of the administrator. However, the Court of Appeals found that the administrator had not relied upon an application of the relevant evidence to the occupational standard. The Court found that the administrator’s physician had not given reasons for his conclusions, never discussed the employee’s job duties, and had evaluated the Plaintiff’s ability to do sedentary work even though the term “sedentary work” did not appear in the plan’s terms. In the addition, the Court found that the administrator had given greater weight to its physician than to the employee’s treating doctor, even though the physician only performed a file review and never saw the Plaintiff. Therefore, the Court of Appeals reversed the lower court and remanded the case back to them with instructions or remand back to the administrator for a determination of whether or not, under these findings, the Plaintiff was entitled to benefits under the plan.
Once again, in ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions. This case demonstrates that the arbitrary and capricious standard can be overcome if the administrator does not ground its decisions in facts and evidence.
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 AllisonShaw v. AT&T Umbrella Benefit Plan No. 1
In this ERISA case, decided in 2015, the question before the Court is whether a long term disability plan administrator acted arbitrarily and capriciously in denying the claimant/Plaintiff’s long term disability benefits under ERISA.
The Plaintiff was employed as a customer service representative for Michigan Bell. He stopped working as a result of chronic neck pain. He was covered under the Defendant plan. The plan administrator initially paid short term disability benefits on the claim, but he was denied long term disability benefits because the plan administrator determined that there was not objective medical documentation of the claimant’s inability to perform any occupation. However, the Court found that the administrator ignored favorable evidence submitted by the Plaintiff’s treating physicians, selectively reviewed the evidence it did consider from the treating physicians, failed to conduct its own physical examination and heavily relied on non-treating physicians. The Court even went so far as to determine that, not only was the Plaintiff entitled to his long term disability benefits, but that a remand would be a useless formality because the medical records contained objective medical evidence that the Plaintiff was disabled.
In ERISA cases, if there is a clause in the plan, in some states, that gives the administrator discretionary authority to determine the eligibility for short term or long term disability benefits under ERISA or to construe the terms of the plan, rather than the Court reviewing the decisions of the administrator under the de novo standard, the Court reviews under the “arbitrary and capricious” standard which means that the administrator’s decisions in denying the long term disability benefits must be arbitrary and capricious for the Court to overturn the administrator’s decisions. Needless to say, this is a very high standard and very difficult to overcome. However, as this case demonstrates, it is not impossible. The administrator must base his decisions on some quantifiable facts to show the Court that the decision has some basis for the denial. This one did not, and was reversed.
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 Standard Life Insurance Company
In this ERISA case, decided in 2022, the parties agreed to a trial upon submission of documentary evidence but disagreed upon the issues properly before the district court. In the case, the Plaintiff/Employee claimed that the Defendant had wrongfully denied his short term and long term disability benefits under ERISA.
The Plaintiff was employed as a software architect for Lereta, where he had been employed for 23 years. He had been having health problems since 1999, including chronic fatigue syndrome, fibromyalgia, depression and attention deficit hyperactivity disorder. His health deteriorated to a point where he could no longer work a 40 hour week. The employer tried reducing his hours to 32 hours per week, but he was unable to consistently do that. He was then moved to part time, which he worked for a while until he unable to do even that. He submitted a claim for short term disability benefits, which was denied by the plan administrator because he no longer qualified as a full time employee and thus did not qualify for short term and long term disability benefits coverage. The Plaintiff appealed this denial of short term disability benefits stating that the beginning date of his disability was incorrectly determined and that his schedule as set by the employer did qualify him as full time. Upon review, the claims examiner agreed with the Plaintiff and he was paid his maximum short term disability benefits. However, the examiner continued to deny the Plaintiff’s long term disability benefits, based on the fact that the Plaintiff did not work full time. The Plaintiff appealed the denial of his long term disability benefits but the Defendant affirmed its decision. The Plaintiff then filed suit pursuant to ERISA.
The parties agreed to a trial upon documentary evidence and the district court found for the Plaintiff. In doing so, the district court had to interpret the term “regular work week” to decide if the Plaintiff had worked full time, and it had to decide when the Plaintiff became disabled. The Defendant also argued that, if the court found that the Plaintiff was eligible for long term disability benefits, that it should have remanded the case back to the Defendant for analysis of whether the Plaintiff was disabled.
The Court of Appeals examined the issue of the district court’s determination of what a “regular” work week is, and determined that the district court was correct in its determination.
The Court then examined the district court’s determination of when the disability began, and again determined that the district court was correct. The Court examined whether the district court had made a “clear error” which is the standard of review for these questions, and determined that it had not. The Court notes that the “clear error” standard is a high standard for the Defendant to overcome.
However, on the issue of whether or not the case should have been remanded to the Defendant so that the case administrator could determine disability, the Court found that it should have been. The language of the ERISA long term disability plan that the Plaintiff was under required a determination of whether the Plaintiff was disabled as a result of injury or sickness and this question was not before the district court in the initial hearing.
This case is a prime example of how a court is bound by the issues in front of it. Sometimes, this is very frustrating for the parties, but courts can only determine the issues that the parties, through their counsel, have asked the court to determine. If a court strays outside of those issues, that court’s decision will often be reversed and the case remanded to the proper court or agency to make those decisions.
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 AllisonCantor v. AT&T Umbrella Benefits Plan No. 3 & AT&T Services
This ERISA case, decided in 2022, is a case where the Defendants, AT&T and the Plan, were both granted summary judgment. In the case, the Plaintiff/Employee claimed wrongful termination of benefits under ERISA.
In this short term disability claim under ERISA, the Plaintiff was an employee of AT&T whose job duties included installing wires, lifting heavy loads and climbing tall ladders. The Plaintiff began to experience severe migraines, lightheadedness and dizziness and concluded he could not longer perform the duties of his job. The Plaintiff applied for short-term disability benefits. Those short term benefits were initially granted but then terminated short of the 52 week benefit period when an independent medical reviewer concluded that the Plaintiff’s tests were normal and that the Plaintiff’s condition had improved. The Plaintiff appealed this decision unsuccessfully with AT&T and then sued them and the plan. The District Court dismissed the claim on summary judgment. The case is then reviewed by the U.S. Court of Appeals.
Basically, the case turned into a battle of the expert doctors, with each side having a battery of doctors who examined the Plaintiff. The Defendants’ doctors said that the Plaintiff was not disabled. The Court noted that the ERISA benefit plan that the Plaintiff was subject to gave a plan administrator discretion to determine eligibility for short term and long term disability benefits, and so the law said that the Court had to consider whether that administrator’s decision was arbitrary and capricious. The Court notes that a administrator’s decision will be found to be arbitrary “when there is an absence of reasoning in the record.” The Court then reviewed the record and determined that the Defendants’ determination was grounded in sufficient evidence and was adequately explained.
The Plaintiff also argues that the decision of the District Court to reject two items of evidence as being outside the administrative record compiled by the parties prior to case coming to Court was incorrect. The Court examines this exclusion amounted to an abuse of discretion by the District Court. The Court notes that under general ERISA principles, the Court is limited to a review of the administrative record absent certain narrow exceptions, none of which applies in this case. Therefore, the Court upheld the District Court and affirmed the dismissal.
This case demonstrates how difficult it is for the Plaintiff to win a case under the arbitrary and capricious review standard under ERISA. By merely having three peer review doctors on board, without a true independent medical evaluation, the Plaintiff’s short term disability claim was terminated. The case also demonstrates that, almost every time, any facts not included in the administrative record put in front of the carrier before the final denial letter is issued with not be recognized by the Court later. Therefore, it is essential that an employee get all medical proof and any other facts into the administrative record before then. Finally, the case points out that the Defendants took the position that any follow-on long term disability benefit claim had no chance of success because the short term disability claim had not been approved and paid for the full 52 weeks. A disabled employee must always pursue the antecedent short term disability benefits to full exhaustion to make a successful later claim for long term disability 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 AllisonSchwarz v. Hartford Life & Accident Ins. Co.
In this ERISA case, decided in 2020, the Court examines the duty that a Defendant Insurance Company has to the claimant.
In this claim the Plaintiff had cancer. She submitted a claim to the Defendant Insurance Company who initially approved the claim and began paying short term disability benefits. During her treatment, the Plaintiff had a node which tested cancer-free but her physician was unconvinced and recommended chemotherapy. The chemotherapy treatments that the Plaintiff had were beginning to affect her mental state and she had to see a mental health professional. In the interim, the Defendant Insurance Company had its own oncologist evaluate the Plaintiff’s records. Their oncologist noted the mental problems what the Plaintiff was having, but deemed her cancer-free and able to return to work. This is in spite of the Plaintiff’s surgeon’s notes that he had found cancer but was unable to reach the nodes. Based on their oncologist’s report, the Defendant Insurance Company denied the Plaintiff’s claim for short term and long term disability benefits.
The Plaintiff appealed the denial of short term and long term disability benefits and informed the Defendant Insurance Company that she had resumed chemotherapy. In response to this, Defendant Insurance Company commissioned two medical reviews, one by an oncologist and one by a psychiatrist. The Plaintiff pointed out that the psychiatrist hired by the Defendant was missing some of her records. However, the psychiatrist concluded that she had no psychiatric restrictions or limitations. The Defendant’s oncologist was also missing certain records and found no evidence of cancer. The Defendant sent copies of these reports to the Plaintiff’s doctors but did not provide copies of the reports to the Plaintiff or her counsel. Plaintiff’s counsel requested copies of these reports from the Defendant, but the Defendant refused to send the reports until after the appeal process had concluded. Defendant then wrote to Plaintiff’s counsel and said that the appeal had been denied based on the reasons set out by its experts.
The U.S. District Court was having none of that. The Court concluded that the Defendant “failed to substantially comply with ERISA’s procedural obligations” when it failed to provide the claimant with the physician file reviews and that because “she did not see Hartford’s two file reviews until after the final denial, Ms. Schwarz (and her legal counsel) never had the chance to evaluate or rebut the file reviews’ contentions.”
So, we see by this that the Defendant has a duty to treat the Plaintiff fairly and make its processes transparent and, if it does not, the Court will force the Defendant to do so.
If you need assistance navigating your short term or long term disability claim 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 AllisonERISA Claims – Insurance Company Must Establish Reasonable Process
ERISA claims are unique in that the insurance company is responsible for paying a potential claim gets to act as the judge and jury during the claims process. However, the law dictates they must be consistent in this process. Below are guidelines (sections c through e) they must follow regarding their procedures.
(c) Group health plans. The claims procedures of a group health plan will be deemed to be reasonable only if, in addition to complying with the requirements of paragraph (b) of this section –
(1)
(i) The claims procedures provide that, in the case of a failure by a claimant or an authorized representative of a claimant to follow the plan’s procedures for filing a pre-service claim, within the meaning of paragraph (m)(2) of this section, the claimant or representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the claimant or authorized representative, as appropriate, as soon as possible, but not later than 5 days (24 hours in the case of a failure to file a claim involving urgent care) following the failure. Notification may be oral, unless written notification is requested by the claimant or authorized representative.
(ii) Paragraph (c)(1)(i) of this section shall apply only in the case of a failure that –
(A) Is a communication by a claimant or an authorized representative of a claimant that is received by a person or organizational unit customarily responsible for handling benefit matters; and
(B) Is a communication that names a specific claimant; a specific medical condition or symptom; and a specific treatment, service, or product for which approval is requested.
(2) The claims procedures do not contain any provision, and are not administered in a way, that requires a claimant to file more than two appeals of an adverse benefit determination prior to bringing a civil action under section 502(a) of the Act;
(3) To the extent that a plan offers voluntary levels of appeal (except to the extent that the plan is required to do so by State law), including voluntary arbitration or any other form of dispute resolution, in addition to those permitted by paragraph (c)(2) of this section, the claims procedures provide that:
(i) The plan waives any right to assert that a claimant has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal provided by the plan;
(ii) The plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that any such voluntary appeal is pending;
(iii) The claims procedures provide that a claimant may elect to submit a benefit dispute to such voluntary level of appeal only after exhaustion of the appeals permitted by paragraph (c)(2) of this section;
(iv) The plan provides to any claimant, upon request, sufficient information relating to the voluntary level of appeal to enable the claimant to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal, including a statement that the decision of a claimant as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on the claimant’s rights to any other benefits under the plan and information about the applicable rules, the claimant’s right to representation, the process for selecting the decisionmaker, and the circumstances, if any, that may affect the impartiality of the decisionmaker, such as any financial or personal interests in the result or any past or present relationship with any party to the review process; and
(v) No fees or costs are imposed on the claimant as part of the voluntary level of appeal.
(4) The claims procedures do not contain any provision for the mandatory arbitration of adverse benefit determinations, except to the extent that the plan or procedures provide that:
(i) The arbitration is conducted as one of the two appeals described in paragraph (c)(2) of this section and in accordance with the requirements applicable to such appeals; and
(ii) The claimant is not precluded from challenging the decision under section 502(a) of the Act or other applicable law.
(d) Plans providing disability benefits. The claims procedures of a plan that provides disability benefits will be deemed to be reasonable only if the claims procedures comply, with respect to claims for disability benefits, with the requirements of paragraphs (b), (c)(2), (c)(3), and (c)(4) of this section.
(e) Claim for benefits. For purposes of this section, a claim for benefits is a request for a plan benefit or benefits made by a claimant in accordance with a plan’s reasonable procedure for filing benefit claims. In the case of a group health plan, a claim for benefits includes any pre-service claims within the meaning of paragraph (m)(2) of this section and any post-service claims within the meaning of paragraph (m)(3) of this section.
If you need assistance navigating your claim, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, 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 AllisonERISA Claims – Insurance Company Must Establish Reasonable Process
ERISA claims are unique in that the insurance company is responsible for paying a potential claim gets to act as the judge and jury during the claims process. However, the law dictates they must be consistent in this process. Below are guidelines they must follow regarding their procedures.
If you need assistance navigating your claim, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in various states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
§ 2560.503-1 Claims procedure.
(a) Scope and purpose. In accordance with the authority of sections 503 and 505 of the Employee Retirement Income Security Act of 1974 (ERISA or the Act), 29 U.S.C. 1133, 1135, this section sets forth minimum requirements for employee benefit plan procedures pertaining to claims for benefits by participants and beneficiaries (hereinafter referred to as claimants). Except as otherwise specifically provided in this section, these requirements apply to every employee benefit plan described in section 4(a) and not exempted under section 4(b) of the Act.
(b) Obligation to establish and maintain reasonable claims procedures. Every employee benefit plan shall establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations (hereinafter collectively referred to as claims procedures). The claims procedures for a plan will be deemed to be reasonable only if –
(1) The claims procedures comply with the requirements of paragraphs (c), (d), (e), (f), (g), (h), (i), and (j) of this section, as appropriate, except to the extent that the claims procedures are deemed to comply with some or all of such provisions pursuant to paragraph (b)(6) of this section;
(2) A description of all claims procedures (including, in the case of a group health plan within the meaning of paragraph (m)(6) of this section, any procedures for obtaining prior approval as a prerequisite for obtaining a benefit, such as preauthorization procedures or utilization review procedures) and the applicable time frames is included as part of a summary plan description meeting the requirements of 29 CFR 2520.102-3;
(3) The claims procedures do not contain any provision, and are not administered in a way, that unduly inhibits or hampers the initiation or processing of claims for benefits. For example, a provision or practice that requires payment of a fee or costs as a condition to making a claim or to appealing an adverse benefit determination would be considered to unduly inhibit the initiation and processing of claims for benefits. Also, the denial of a claim for failure to obtain a prior approval under circumstances that would make obtaining such prior approval impossible or where application of the prior approval process could seriously jeopardize the life or health of the claimant (e.g., in the case of a group health plan, the claimant is unconscious and in need of immediate care at the time medical treatment is required) would constitute a practice that unduly inhibits the initiation and processing of a claim;
(4) The claims procedures do not preclude an authorized representative of a claimant from acting on behalf of such claimant in pursuing a benefit claim or appeal of an adverse benefit determination. Nevertheless, a plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant, provided that, in the case of a claim involving urgent care, within the meaning of paragraph (m)(1) of this section, a health care professional, within the meaning of paragraph (m)(7) of this section, with knowledge of a claimant’s medical condition shall be permitted to act as the authorized representative of the claimant; and
(5) The claims procedures contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated claimants.
(6) In the case of a plan established and maintained pursuant to a collective bargaining agreement (other than a plan subject to the provisions of section 302(c)(5) of the Labor Management Relations Act, 1947 concerning joint representation on the board of trustees) –
(i) Such plan will be deemed to comply with the provisions of paragraphs (c) through (j) of this section if the collective bargaining agreement pursuant to which the plan is established or maintained sets forth or incorporates by specific reference –
(A) Provisions concerning the filing of benefit claims and the initial disposition of benefit claims, and
(B) A grievance and arbitration procedure to which adverse benefit determinations are subject.
(ii) Such plan will be deemed to comply with the provisions of paragraphs (h), (i), and (j) of this section (but will not be deemed to comply with paragraphs (c) through (g) of this section) if the collective bargaining agreement pursuant to which the plan is established or maintained sets forth or incorporates by specific reference a grievance and arbitration procedure to which adverse benefit determinations are subject (but not provisions concerning the filing and initial disposition of benefit claims).
(7) In the case of a plan providing disability benefits, the plan must ensure that all claims and appeals for disability benefits are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. Accordingly, decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical or vocational expert) must not be made based upon the likelihood that the individual will support the denial of benefits.