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.
by Cody AllisonLimitations Periods in ERISA LTD Claims Following the 2018 Regulation Changes
On April 1, 2018, The Secretary of Labor’s (DOL) new regulations concerning review of ERISA claims went into effect. These new regulations were put into place to create a fairer system within the ERISA claims review process. “Limitations Periods” was one of the areas on which the DOL focused.
“Limitations Periods” refers to the time a claimant has to file an appeal, or bring a lawsuit after denial by the insurance company. Prior to the 2018 regulation changes, this issue often presented a problem for claimants. Because the time limitation to file an appeal or lawsuit was not always clear in the denial letter, many claimants did not file their appeals or lawsuits in time and were forced to forfeit their claims forever.
Typically, a claimant has 180 days to file an appeal following denial of an ERISA long-term disability claim. A claimant may also ask the insurance carrier for an extension of that time which may or may not be granted. Prior to the regulation changes in 2018, once the appeal was denied, the claimant would need to check the policy language regarding timelines to file a lawsuit and make a calculation of the time limitation. If miscalculated, the claimant may wait too late to file a lawsuit and waive their right to make any claim under the policy. Following the 2018 regulation changes, the insurance carrier is required to put a specific date on which the limitation period to file a lawsuit expires in the denial letter.
An ERISA long-term disability appeal needs to be carefully crafted in order to put all relevant information in front of the claims adjuster. In ERISA long-term disability cases, once the appeal time limitation is exhausted no additional information can be added to the claims file (also known as the Administrative Record). This means that if you file a lawsuit, only the information contained in the Administrative Record at the time of the final denial can be considered by the Court. Therefore, it is very important to craft an appeal that puts all relevant evidence before the claims adjuster.
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a FREE lawyer consultation.
You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
by Cody Allison2018 DOL ERISA REGULATION AMENDMENTS – NEW EVIDENCE
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
On April 1, 2018, The Secretary of Labor’s (DOL) new regulations concerning review of ERISA claims went into effect. These new regulations were put into place to create a fairer system within the ERISA claims review process. “New Evidence” was one of the areas on which the DOL focused.
“New Evidence” refers to any information added to the Administrative Record in the appeal period on which the insurance company will rely in making a benefit determination. The Claimant must be given timely notice of this new information and the opportunity to respond.
While insurance companies opposed this provision being added to the new regs. They have since been forced to modify their processes to given claimants a reasonable opportunity to respond to the new information. Prior to this regulation change it was not uncommon for an insurance company to send a final denial letter that contained a report from a doctor they hired to review the claim. This final denial would end the appeal process and the claimant did not have an opportunity to review the report, or better yet, have their doctor review the report, prior to the time the claims file (Administrative Record) would close. As many could see, this old process gave the insurance company a tremendous advantage in having the last word.
While having an opportunity to respond to “New Evidence” is a good for the claimant it can cause the appeal process to drag out for a greatly extended period of time. Remember, the Administrative Record closes after final denial and only in extremely limited circumstance can any information be added to the record after that point. If given a final denial, you will bring the Administrative Record, as it exists at the time of final denial, into court should you pursue a lawsuit after that point. It is very important to add all information in your favor to the Administrative Record prior to final denial.
by Cody AllisonERISA Fibromyalgia Case
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
We get calls from clients wanting to know the law as it relates to making a claim under their ERISA policy for fibromyalgia.
The case of Demco v. Unum Life Ins. Co. of America, 2019 U.S. App. LEXIS 31102 (9th Cir. October 15, 2019) looks at an appeal of a dismissal in a fibromyalgia case.
Plaintiff Kelly Demko (“Demko”) was diagnosed with fibromyalgia in 2009, but thereafter continued to work as a human resources executive for Amblin Entertainment. In January 2016, Demko stopped working and submitted a claim for long-term disability (LTD) benefits under her employer’s LTD plan, claiming her fibromyalgia had become disabling, with “all over deep pain, foggy feeling, [and] severe depression.”
In the months before she stopped working, Demko’s medical records revealed that her fibromyalgia-related complaints were generally stable and well-controlled, and her diagnostic findings and physical examinations were normal, with no exacerbation or change in her condition. Additionally, Demko’s prescribed treatment plan was conservative and lacked the more aggressive pain management and other treatment techniques one would expect for a patient with the disabling complaints Demko reported to Unum Life Insurance Company of America (“Unum Life”). Furthermore, Demko’s psychiatrist reported that her cognitive functioning was normal, and her primary care physician routinely recorded normal mental status and cognitive functioning examination results.
Unum Life also contacted Demko’s employer, who reported that Demko’s work performance and work schedule had not changed in any way before she stopped working. The employer told Unum Life that Demko had stopped working because she was “terminated due to violation of company policy.”
The district court reviewed Unum Life’s claim decision de novo. In affirming the decisions, the court concluded that Demko did not show that her medical conditions rendered her totally disabled under the plan, and added that “mere subjective” complaints are insufficient to establish total disability.
Demko appealed to the Ninth Circuit. A panel of three judges affirmed the district court’s decision, concluding that the court did not err in finding that Demko “was able to perform her job normally until she was terminated for non-medical reasons.” The Ninth Circuit also rejected Demko’s objections to the district court’s evaluation of the evidence. The panel noted, inter alia, that the court had accorded Demko’s treating physicians the “greatest weight” and did not rely heavily on the opinions offered by Unum Life’s doctors, and also held that “an independent medical examination was not required, particularly when Demko proffered insufficient evidence to establish disability.” Additionally, the panel held that “the district court duly considered Demko’s subjective complaints, and reasonably concluded that they did not establish the requisite level of disability.”
by Cody AllisonHow To File A Claim for Your ERISA Disability Benefits.
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
How do you file a claim for your disability benefits under ERISA. Before you even get to the point of needing an attorney’s help, you will need to file claim for your benefits to “get the ball rolling.” How do you do that.
Below is link to helpful information from the U.S. Department Labor, Employee Benefits Security Administration, that sets out the process for making a claim for your benefits.
Once you have made this claim, you may run into problems. Contact us — we can help you.
by Cody AllisonCan ERISA Plan Administrator Change Its Mind on Sufficiency of Evidence?
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
In Geiger v. Aetna Life Ins. Co., 845 F.3d 357 (7th Cir. 2017), Aetna initially determined that plaintiff qualified for disability benefits due to bilateral avascular necrosis in her ankles, which prevented walking and driving. When the definition of disability was about to change, Aetna conducted an Independent Medical Exam, which found her capable of sedentary work, and had plaintiff surveilled, which showed her driving and visiting multiple stores. Aetna terminated benefits. On appeal, Aetna reinstated benefits in May 2013, after one of two peer reviewers determined she was not capable of sedentary work.
Aetna later conducted additional surveillance, again showing plaintiff driving and shopping, and terminated benefits again in May 2014, based on a nurse’s clinical review and a Transferrable Skills Analysis. On appeal, Aetna had obtained a third peer review, which concluded that plaintiff could perform sedentary work. Aetna also sent the peer review and surveillance to plaintiff’s doctors; only one responded, and said that the surveilled activities were the result of substantial amounts of pain medication. A follow up peer review did not change the initial conclusion.
Plaintiff argued that Aetna’s decision was arbitrary and capricious because it “relied on the same evidence it had previously considered when it reinstated her benefits, yet reached the opposite conclusion. Specifically, plaintiff claimed, the second round of surveillance observed the same activities as the first round. Plaintiff relied on a 2009 case, Leger v. Tribune Co., which held that a plan should not be allowed to relitigate what it already decided. The court rejected this argument, explaining: “Leger did not hold that a plan administrator’s prior determination in favor (or against) a claimant operates forever as an estoppel so that an insurer can never change its mind. … Indeed, ERISA does not prohibit a plan administrator from performing a periodic review of a beneficiary’s disability status. [quotation marks omitted].”
The court also rejected plaintiff’s argument that the district court abused its discretion in not allowing depositions of the peer reviewer and vocational consultant. The court approved the district court’s finding that Aetna had minimized any conflict of interest by obtaining numerous independent peer reviews; by reaching out to plaintiff’s doctors; by sending its surveillance to plaintiff’s doctors; and by previously reversing its own conclusion and reinstating benefits.
by Cody AllisonIntersection between ERISA and the Americans with Disabilities Act
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
In the case of Rider v. Bluegrass Oxygen, Inc., 2019 WL 4934187 (E.D. Ky. 2019), the Court examined how the Americans with Disabilities Act and ERISA plans fit together.
An employee covered by his employer’s medical plan was terminated four years after the birth of his daughter who was diagnosed with cystic fibrosis and prescribed a medication costing $300,000 per year. The employee sued his employer under the Americans with Disabilities Act (ADA) for discrimination based on association with a person with a disability, arguing that the termination was due to his daughter’s condition. He also claimed the employer violated ERISA § 510 by retaliating against him for filing large health plan claims. The employer asserted that the employee’s termination was due to his poor performance as a branch manager, presenting evidence of a significant decrease in the branch’s profitability, declining income, the loss of a competitive government bid, and increased inventory losses, among other things. For three years, the employer had allegedly conducted monthly discussions with the employee regarding his performance issues, which the employee disputed.
Despite evidence of legitimate business-related reasons for termination, an employee can still prevail on an ADA claim by establishing that the reasons given were mere pretext by showing that those reasons have no basis in fact, did not actually motivate the termination, or were insufficient to warrant the termination. To prove the increase in medical claim costs motivated his termination, the employee cited a discussion with the human resources manager about whether there was a lower-cost option for his daughter’s medication and an email exchange between that manager and an insurance broker who said the employee’s daughter “jacked up [the plan’s] claims through the ceiling.” Because these individuals were not decisionmakers regarding his employment, however, and the instances cited occurred years prior to his termination, the court held that the employee failed to prove a discriminatory motive on the part of the employer. Regarding the ERISA claim, the court held the employee failed to demonstrate that the employer terminated him to interfere with his benefit rights. The employer’s motion for judgment without trial was granted, and the case dismissed.
So, we can see in this case that an employee can’t be fired for a reason that violates the ADA, and firing a person because they have a family member whose medical costs are going to be very expensive and thus increase the costs of the ERISA plan would be discriminatory. However, the employee has the burden of proving that the firing was because of the increased costs of the plan and not for other, legitimate business reasons.