by Cody AllisonColby v. Union Sec. Ins. Co.
In this 2013 ERISA case, the plaintiff claimant exhausted her administrative appeals and brought suit against defendant long term disability plan administrator. The parties cross-moved for judgment on the record and the United States District Court for the District of Massachusetts deemed the administrator’s termination of benefits unreasonable. The administrator appealed.
The central question was whether, in addiction context, a risk of relapse could be so significant as to constitute a current disability. Although its decision created a circuit split, the instant court answered the question affirmatively. A risk of relapse into substance dependence – like a risk of relapse into cardiac distress or a risk of relapse into orthopedic complications – could swell to so significant a level as to constitute a current disability. The holding was narrow. It pivoted on a fusion of the plain language of the plan and the administrator’s all-or-nothing approach to its benefits determination. The administrator could have written into the plan an exclusion for the risk of relapse, but it did not choose to do so. Without such a written exclusion in place, the administrator acted arbitrarily and capriciously in refusing to consider whether the claimant’s risk of relapse swelled to the level of a disabililty. A benefits determination could not be reasoned when the plan administrator sidestepped the central inquiry. Further, the district court did not abuse its discretion in awarding retroactive benefits. It already had remanded the case once, to no avail.
The district court’s decision was affirmed.
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 AllisonSloan v. Hartford Life and Accident Ins. Co.
In this 2006 ERISA case, the appellant insurer challenged the U.S. District Court’s determination that the appellee injured party qualified for long-term disability benefits under a plan governed by ERISA. The court first addressed the insurer’s argument that the district court abused its discretion in admitting evidence outside the administrative record. As to the duplicative medical evidence, it held that the district court did not abuse its discretion. As for the nonduplicative new evidence considered, two reasons given by the district court were sufficient to support its decision, i.e., the social security definition of disability was very similar to the definition in the plan, and the district court considered the administrative law judge’s credibility determinations regarding the subjective complaints of pain to be highly probative of the ultimate question of disability. The court turned next to the finding that the injured party qualified for LTD benefits. Under the clear error standard, there was enough evidence to support the findings. Finally, because there was simply no legitimate basis for the insurer’s contention regarding a potential offset of social security benefits at a point in time earlier than January 2001, the district court committed no error when it failed to remand the case to allow the insurer the first opportunity to calculate the offset administratively.
The district court’s decision was affirmed.
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 AllisonHampton v. Reliance Std. Life Ins. Co.
In this 2014 ERISA case, where a claimant was diagnosed with insulin-dependent diabetes mellitus, a claims-review fiduciary did not abuse its discretion under ERISA by denying his claim for long-term disability benefits. It was reasonable for the fiduciary to interpret the plan to require that the claimant show that the injury or sickness itself, independent of the loss of license, rendered him unable to perform his occupation. Substantial evidence supported the fiduciary’s determination that the claimant was not totally disabled because although his physician opined that the claimant would be unable to work as an over-the-road truck driver based on the Department of Transportation’s regulations, he identified no physical limitations on the claimant’s ability to do so as a direct result of his diabetes.
Judgment reversed, fee award vacated.
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 AllisonRote v. Titan Tire Corp.
In this 2010 ERISA case, the Appellate pan administrator appealed from the U.S. District Court for the Southern District of Iowa, which held that the administrator abused its discretion in denying appellee employee’s application for long-term disability benefits. The district court also awarded the employee attorney’s fees incurred from the date she filed her original suit in district court.
The court agreed that the administrator abused its discretion in denying the employee’s application for long-term disability benefits under ERISA. The administrator’s sole reason for denying the employee’s application was that she had not shown her disability to be “permanent.” To reach that conclusion, the administrator interpreted doctors’ letters as suggesting that the employee’s restrictions were not permanent, focusing on the use of the term “indefinitely” and relying on one dictionary definition of “indefinite.” However, the court ruled that the intended meaning of “indefinitely” — that the restrictions were permanent — was clear from the context of the letters that the employee’s attorney and the doctors exchanged. The court found no abuse of discretion in the district court’s decision to award attorney’s fees pursuant to the statute. The administrator relied on a hypertechnical reading of the medical evidence and ignored the doctors’ attempts to clarify their opinions. Additionally, there was evidence that the administrator attempted to frustrate the employee’s ability to move the claims process forward.
The judgment of the district court was affirmed.
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 AllisonAvenoso v. Reliance Std. Life Ins. Co.
In this 2021 ERISA case, the district court’s entry of summary judgment in favor of the 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 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. The judgment of the lower court was affirmed.
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 AllisonZurndorfer v. Unum Life Ins. Co. of Am.
In this 2008 ERISA case, the Plaintiff insured brought an acation against the Defendant plan administrator pursuant to ERISA, seeking reinstatement of long-term disability benefits. Before the Court were the administrator’s motion for judgment on the administrative record and the insured’s motion for summary judgment
After the insured had shoulder surgery, she did not return to her job as a sales person. The insured sought long-term disability benefits based primarily on her multiple sclerosis (MS). The administrator approved the insured’s claim and assisted the insured in obtaining Social Security Disability benefits. The administrator subsequently terminated the insured’s long-term disability benefits, finding that there was no change in the insured’s MS when she stopped working, that the insured’s MS had stabilized, and that the insured was able to return to work once she recovered from her surgery. The court held that the administrator’s determination that the insured was no longer disabled was arbitrary. The administrator refused to consider evidence showing that before the insured stopped working, she regularly fell and had difficulty walking and using stairs. That the insured’s MS was stable during chemotherapy did not control a determination concerning the insured’s condition non months after the treatment had ended. The administrator did not rationally address how the insured would be able to perform a job that requir3ed significant travel while carrying presentation materials.
Holding that the insured was entitled to reinstatement of her long-term disability benefits and an award of attorney’s fees, the court denied the administrator’s motion for judgment on the administrative record and granted the insured’s motion for summary judgment.
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 AllisonCook v. N.Y. Times Co. Group Long Term Disability Plan
In this 2004 ERISA case, the employee claimed to suffer from chronic fatigue syndrome. Neither the initial claim denial nor the subsequent determinations on appeal explained why these findings in her initial statement and her subsequent lengthy and detailed appeal letter were insufficient. Inter alia, the court held that the plan administrator was entitled to evaluate the evidence submitted and find it lacking on any reasonable ground. However, it was not entitled to fail to inform the employee of why the evidence she had submitted was found deficient in the first place. Although the denial letter on which plaintiff’s second appeal was based was far more specific than the first denial letter, it still failed to include the criteria upon which the determination was based and to inform the employee of her rights to access her file. Because the denial notice on the second appeal again failed to provide the required information, the denial of the third appeal also violated ERISA. The administrator’s failure to provide the required information as to the criteria it relied upon and the rights attendant upon the appeal rendered its determination so procedurally flawed as to be arbitrary and capricious.
The ERISA plan’s motion for summary judgment was denied and its determination vacated. The employee’s cross-motion for summary judgment was granted to the extent that the plan administrator’s determination was vacated but was otherwise denied. The case was remanded to the plan administrator for reconsideration. The employee’s request for costs and attorney’s fees was granted.
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 AllisonTranbarger v. Lincoln Live & Annuity Co.
In this 2023 ERISA case, the Court held that the trial court properly concluded that the plaintiff failed to demonstrate complete and continuous disability during the six months following her resignation under ERISA because ample evidence suggested that she could perform some work in some instances based on the report from her physical therapy sessions, which described her to moving well and suffering no pain, at the time. Also, her supervisor suggested that she could still perform some of her main duties as an accounts receivable manager. The lower court was affirmed.
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 AllisonD.K. v. United Behavioral Health
In this 2023 ERISA case, the Court held that when reviewing a claim for benefits, an administrator is not required to defer to the opinions of a treating physician. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831, 123 S. Ct. 1965, 155 L. Ed. 2d 1034 (2003). However, a reviewer may not arbitrarily refuse to credit such opinions if they constitute reliable evidence from the claimant. Id. at 834. Medical opinions are regularly proffered as proof of a claim, and we have held reviewers “cannot shut their eyes to readily available information . . . [that may] confirm the beneficiary’s theory of entitlement.” Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 807 (10th Cir. 2004). Therefore, if United arbitrarily refused to credit and effectively “shut their eyes” to the medical opinions of A.K.’s treating physicians, it acted arbitrarily and capriciously.
United also argues the district court abused its discretion when it awarded A.K. benefits outright. HN20 A court may remand for further administrative review if it determines the administrator’s flawed handling could be cured by a renewed evaluation to address, for example, [*39] a “fail[ure] to make adequate findings or to explain adequately the grounds for a decision.” Caldwell v. Life Ins. Co. of N. Am., 287 F.3d 1276, 1288 (10th Cir. 2002). See also Rekstad v. U.S. Bancorp, 451 F.3d 1114, 1121-22 (10th Cir. 20026) (remanding for plan administrator to examine relevant evidence). By contrast, a court may award benefits when the record shows that benefits should clearly have been awarded by the administrator. See Weber v. GE Grp. Life. Assurance Co., 541 F.3d 1002, 1015 (10th Cir. 2008). That is not the only instance in which a court may award benefits. If a plan administrator’s actions were clearly arbitrary and capricious, then remand is unnecessary, and a reviewing court may award benefits. DeGrado v. Jefferson Pilot Fin. Ins. Co., 451 F.3d 1161, 1175-76 (10th Cir. 2006). Other circuits have similarly found remand unnecessary for procedural flaws. HN21 As the Second Circuit explained, remand to an insurer is not appropriate if it “serve[s] primarily to give the defendants an opportunity to retool a defective [appeals] system.” Zervos v. Verizon New York, Inc., 277 F.3d 635, 648 (2d Cir. 2002). The Ninth Circuit has expressed concern with giving an additional “bite at the apple” to ERISA administrators acting unjustly. See Grosz-Salomon v. Paul Revere Life Ins. Co., 237 F.3d 1154, 1163 (9th Cir. 2001).
In considering if such a rule is appropriate here, we consider the function of judicial review for ERISA administrators. HN22 The Supreme Court has reiterated that judicial deference to ERISA plan administrators is premised on their fiduciary roles. See, e.g., Varity Corp. v. Howe, 516 U.S. 489, 506, 116 S. Ct. 1065, 134 L. Ed. 2d 130 (1996). ERISA requires fiduciaries to “discharge [*40] [their] duties with respect to a plan solely in the interest of the participants and beneficiaries.” 29 U.S.C. § 1104. When the administrator’s actions or structure threaten their ability to act as a proper fiduciary, the Court has given administrators’ decisions less deference. See Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 107-09, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989) (disallowing the arbitrary and capricious standard of review when there is a possible conflict of interest for the administrator); Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 118, 128 S. Ct. 2343, 171 L. Ed. 2d 299 (2008) (disallowing deferential review when considering the specific facts of the case). When Congress “careful[ly] balance[ed] the need for prompt and fair claims settlement procedures against the public interest in encouraging the formation of employee benefit plans,” Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 54, 107 S. Ct. 1549, 95 L. Ed. 2d 39 (1987), it did not give administrators unlimited freedom to act improperly towards claimants.
We conclude that the district court did not abuse its discretion in declining to remand. Considering the administrator’s clear and repeated procedural errors in denying this claim, it would be contrary to ERISA fiduciary principles to mandate a remand and provide an additional “bite at the apple.” ….
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 AllisonMosely v. Unum Life Ins. Co. of Am.
In this 2023 ERISA case, the Defendant ceased providing disability benefits to the Plaintiff pursuant to a mental illness limitation of her long-term disability policy. The Plaintiff challenged this decision, arguing that the Defendant abused its discretion by finding that the basis for her disability is psychological rather than physical. The Defendant moved for summary judgment. The Court examined the record and immediately notes that the Defendant failed to provide the Plaintiff with an independent medical examination (IME) when she requested it, and that constituted a procedural error and rendered the Defendant’s benefits determination inherently arbitrary and capricious. For this reason, the Court denied the Defendant’s motion for summary judgment and remanded the case for an IME to be conducted.
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.