by Cody AllisonDonachie v. Liberty Life Assur. Co.
In this 2014 ERISA case, a claimaint suffering from anxiety due to the noise from a prosthetic valve with each beat of his heart after surgery that replaced his aortic valve, was erroneously denied long term disability benefits because the plan administrator ignored substantial evidence for the claimant’s treating physicians that he was incapable of pe3rforming his current occupation, while failing to offer any reliable contrary evidence.
In denying the claimaint’s attorneys’ fees, the district court abused its discretion because it inadequately addressed two important fee factors and erred in considering the absence of bad faith on the part of the administrator as the most salient fee factor; fees should have been awarded since they furthered the policy interest in vindicating the rights secured by ERISA.
The lower court’s decision was affirmed in part and vacated and remanded in part.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonMcQuillin v. Hartford Life & Accident Ins. Co.
In this 2022 case, the question is whether the beneficiary of the plan timely brought suit in federal court – whether or not he had exhausted his plan remedies. The lower court determined that he had not exhausted his remedies and dismissed his suit, from which the beneficiary appealed. The beneficiary argued that the remedies should have been deemed exhausted because the insurer, in violation of the applicable ERISA regulation, failed to provide a final decision on his benefits within 45 days of the administrative appeal. The Court notes that the appropriate ERISA statute requires that the insurer “strictly adhere” to the 45 day window in which to render its decision, absent extraordinary circumstances. Here, there were no extraordinary circumstances as contemplated by the statute, so the insurer did not strictly comply with the 45 day deadline, and the beneficiary’s remedies were exhausted, and he timely filed suit. Therefore, the lower court is reversed and the suit is reinstated.
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 AllisonLyncker v. Johnson & Johnson Pension Comm.
In this 2006 case, the claimant sought review of a decision in which defendant, a pension committee, terminated the claimant’s long-term disability benefits. Those benefits had issued under a plan governed by ERISA. The claimant moved for summary judgment, and the committee moved for final judgment based on review of the administrative record. The claimant also moved for an award of attorney’s fees.
The claimant, who had severe asthma, received benefits under the “own occupation” plan’s definition of disability, but her benefits were discontinued under the “any occupation” definition that started when the “own occupation” period ended because the committee determined that the claimant could perform sedentary work. The Court held that the committee acted arbitrarily and capriciously in terminating benefits. The claimant’s treating physician had consistently opined that the claimant’s asthma rendered her incapable of sedentary work. However, the committee’s reviewing physicians ignored the opinion of the treating physician, took his comments out of context, and mischaracterized verbal statements that the treating physician had made. The committee then relied on the opinions of its reviewing physicians, who had not examined the claimant, to find that she could perform sedentary work. The unreasonableness of the committee’s decision was underscored by the fact that it granted benefits under the more rigorous “own occupation” standard and terminated benefits under the less rigorous “any occupation” standard despite the lack of any noticeable improvement in the claimant’s condition.
The Court granted the claimant’s motion for summary judgment, denied the committee’s motion for final judgment based on review of the administrative record, reversed the committee’s decision and remanded the case to the committee for reinstatement of the claimant’s benefits. The claimant’s request for attorneys’ fees would be considered upon the filing of a formal motion therefor.
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 case, the Appellant Plan Administrator appealed from the U.S. District Court, which held that the Administrator abused its discretion in denying appellee employee’s application for long term disability benefits and ordered the Administrator to pay the Employee disability benefits and to pay the Employee’s attorney’s fees. The Administrator appealed.
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 “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. 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.
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 AllisonGroves v. Metro. Life Ins. Co.
In this 2005 case, the Appellant employee appealed from the U.S. District Court which granted summary judgment in favor of the insurer after the employee challenged the insurer’s termination of his long term disability benefits by filing a claim under ERISA.
The insurer reviewed the employee’s extensive medical records and then sent them to an independent physician consultant. This independent physician reported that the employee’s conditions prevented him from working as a truck driver, but the employee retained functional abilities with sedentary to light work capacity level. The insurer then asked the employee’s treating physician to comment on the independent physician’s report. The treating physician’s opinion was that the employee may have been able to perform at the sedentary level. However, the treating physician also did not think that the employee was employable, and remained of the opinion that he should have been considered permanently disabled and incapable of even the most sedentary occupation. Under the applicable deferential standard of review, the court concluded that substantial evidence supported the insurer’s decision to terminate the employee’s long term disability benefits. It was not unreasonable for the insurer to reject the treating physician’s opinion in favor of the independent physician’s opinion in deciding to terminate the employee’s ERISA 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 AllisonSchmitz v. Sun Life Assur. Co.
The Plaintiff in this case was terminated from his job in July 2008 based on poor work performance. While he worked for his employer, he had a long term disability policy under ERISA. In October, 2011, he was diagnosed with multiple sclerosis and he applied for benefits under the Defendant’s policy. He claimed that his poor job performance was caused by the mental health and cognitive problems associated with his then-undiagnosed MS. Of course, the Defendant denied the benefits based on the determination that the Plaintiff was not disabled at the time of his termination. He brought suit, and the district court dismissed his case on summary judgment. He appeals.
The Court notes that the policy required Plaintiff to provide written notice of his claim within 30 days of a set period of time and to provide proof of the claim no later than 90 days after the end of period. The policy also had a limitations period requiring and lawsuit for benefits to be brought within 3 years of the date the proof of claim was required. The Court finds, despite the Plaintiff’s arguments to the contrary, that the Plaintiff did not file suit until after the limitations period had expired and therefore the Plaintiff’s lawsuit is untimely. The Court affirmed the lower court.
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 an ERISA long term disability case, the district court’s entry of summary judgment in favor of a claimant was affirmed because, while the court adjudicated the parties’ summary judgment motions as if it were ruling in a bench trial, whether the district court’s decision survived de novo review of its legal determinations and clear error review of its factual findings turned on whether it clearly erred in finding the claimant lacked sedentary work capacity on the record before it, the appellate court could not say the district court’s finding that the claimant lacked sedentary work capacity was clearly erroneous, and it had to disregard as harmless the district court’s error in adjudicating the parties’ motions for summary judgment as if it were ruling in a bench trial.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonMarcin v. Reliance Std. Life Ins. Co.
In a challenge to the denial of benefits, the district court properly awarded ERISA benefits on the basis that the Plaintiff proved partial disability. According to the express terms of the long term disability plan, partial disability was the equivalent to total disability, and the Plaintiff was totally disabled with the relevant period. Because the Plaintiff proved partial disability, the plan administrator acted unreasonably in denying her benefits. The Court affirmed the lower court’s judgment determining that the Plaintiff was entitled to benefits, and the amount of benefits owed.
As we have said over and over in this blog, the policy controls. Here, the plan allowed the Plaintiff to merely prove partial disability to be considered totally disabled. The Court enforced this provision, as it should have.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonCollier v. Lincoln Life Assurance Company of Boston
Previously in this blog, we have examined what the duties and responsibilities of a claimant in the review of a claim, and what are the duties and responsibilities of a Plan Administrator. This case deals with the duties and responsibilities of the court in these reviews.
In this case, the U.S. Court of Appeals reversed the district court’s judgment in favor of the Defnedant and remanded the case in an ERISA action brought by the Plaintiff.
The Plaintiff challenged the Defendant’s denial of her claim for long-term disability benefits. On de novo review, the district court affirmed the Defendant’s denial, but it adopted new rationales that the ERISA plan administrator did not rely on during the administrative process. Specifically, the district court found for the first time that the Plaintiff was not credible and that she failed to supply objective evidence to support the claim.
The Court held that when a district court reviews de novo a plan administrator’s denial of benefits, it examines the administrative record without deference to the administrator’s conclusions to determine whether the administrator erred in denying benefits. The district court’s task is to determine whether the plan administrator’s decision is supported by the record, not to engage in a new determination of whether the claimant is disabled. Accordingly, the district court must examine only the rationales the plan administrator relied on in denying benefits and cannot adopt new rationales that the claimant had no opportunity to respond to during the administrative process.
The Court held that the district court erred because it relied on new rationales to affirm the denial of benefits. As Defendant did not present these rationales during the administrative process, Plaintiff was afforded no opportunity to respond to them, and was denied her statutory right to “full and fair review” of the denial of her claim. The Court reversed and remanded the case to the district court to reconsider the Plaintiff’s claim de novo, with no deference to the administrator’s decision, and to determine whether the record evidence supports the reasons on which the Defendant relied to deny benefits.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonRushing v. Sun Life Assurance Co of Canada
This is an unusual case under ERISA.
Matthew Rushing died as a result of an auto accident. His wife, Katie Rushing (“Plaintiff”), filed a claim for benefits under an Accidental Death and Dismemberment Policy in which the Rushings participated as part of an employee benefits plan issued through Katie’s employer. Sun Life Assurance Company of Canada (“Sun Life”) is the insurer and administrator of the policy.
Sun Life denied the claim on the grounds that Mr. Rushing’s death did not meet the definition of an accident under the policy. Plaintiff filed this civil action to challenge that decision under the applicable ERISA standard of review. Sun Life, after suit was filed, communicated to Plaintiff that the results of Mr. Rushing’s toxicology report also provided grounds for denial of the claim. Sun Life filed a Motion to Stay and to Remand for Administrative Review that is now before the court. Sun Life urges that its new basis for denying the claim was not thoroughly evaluated during the administrative review process so is not ripe for a judicial determination. Plaintiff responds that Sun Life conducted the administrative review process with the toxicology report in hand, and it should not now be allowed a second round of administrative proceedings to urge a defense that it could have asserted the first time. For the reasons that follow, Sun Life’s motion will be denied….
Sun Life[’s] … reasoning was that the car suddenly crossed the center line with no known reason such as weather or mechanical problems. Plaintiff had a full and fair opportunity to challenge that reasoning during the administrative process. After the case arrived in court, Sun Life sought for the first time to point to other evidence, in the form of the toxicology report and its belief about the effect of the level of substances in Matthew’s system, as a new basis for its decision that Matthew’s death was not caused by an accident. The record indicates that Sun Life was in possession of the toxicology report early in the administrative process .…
Remand may be appropriate to provide a remedy to a claimant who has been denied a full and fair opportunity to address an issue during the administrative process, but it is not appropriate for the plan or insurer to wait until a case is in federal court and then seek remand to build a new basis for denial that it reasonably could have developed during the administrative process. Sun Life … should not now be allowed to further delay the proceedings to go back and attempt to improve its position. For these reasons, the court finds that the best exercise of its discretion in these circumstances is to deny a remand and proceed with having the parties stipulate to the contents of the administrative record and briefing the merits. Accordingly, Sun Life’s Motion … is denied.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.