Tag Archives: ERISA

ERISA: Appeal must be clear

In Reindl v. Hartford Life and Accident Insurance Co., –F.3d __, 2013 WL 425356 ( 8th Cir. February 5, 2013), the 8th Circuit clearly stated that when appealing an ERISA decision – the appeal must be clear.  In this case, the question was: Can a mere request for medical records, and a reference to an “appeal in the future tense,” trigger the appeal?  The 8th Circuit held no.

Here, the participant sought and obtained disability benefits.  Hartford later reassessed the claim of the participant and discontinued the benefits.  On November 25, 2008, Hartford sent a letter informing the participant that she had 180 days to file an administrative appeal.

On December 12, 2008, the participant’s lawyer sent a letter requesting medical records and stating, “We will be reviewing the records and obtaining additional medical information for my client’s appeal of the decision to terminate [benefits].” (emphasis added).

On July 8, 2009 the participant’s attorney expressed disagreement with the benefits termination decision and stated: “I would appreciate your reversal of the decision to terminate [Reindl’s benefit claim].”

The trial court held that the participant failed to file a timely appeal.  The 8th Circuit affirmed.  The 8th Circuit court reasoned that the December letter merely requested medical records.  The reference to a future appeal was not an actual appeal.

via 8th Circuit – Expressing Intent to Appeal in the Future Does Not Constitute an “Appeal.” | Boom: The ERISA Law Blog.

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ERISA: Is risk of relapse a disability?

This ERISA long-term disability case brings an interesting question.  Is an individual still disabled even though the disabling event has already passed – just because of the possible risk of relapse?  In other words, if person A had a disability event in 2000, is person A still considered disabled just because of what might or might happen in the future?

In Colby v. Union Sec. Ins. Co., 11-2270, the First Circuit Court of Appeals decided just that.  In this case, the issue was whether the future risk of relapse by an anesthesiologist who had been diagnosed with addition rendered the anesthesiologist disabled for purposes of a long-term disability policy.

The First Circuit Court of Appeals decided this case based on the language of the policy.  Under the policy language, covered “sickness” including mental health issues, including substance abuse, dependence, and addiction.  While in treatment, plaintiff’s doctors consistently held that the risk of relapse was “high” and recommended plaintiff not return to work for a period of 6 months.  Shortly thereafter, plaintiff relapsed.  After the relapse and due to the continuing high risk of relapse, plaintiff’s doctors agreed plaintiff should remain disabled for some period of time after plaintiff’s discharge.

This case arose because the the insurance company maintained that the risk of relapse (regardless of the degree) did not constitute as a disability under the plan.

After looking at the policy language, the First Circuit Court of Appeals disagreed.  There was nothing in the policy that stated that risk of relapse should not be covered as a disability.  The court stated,

To begin, the language of the plan admits of no such categorial bar.  It does not mention risk of relapse, let alone exclude risk of relapse as a potential basis for a finding of disability.

In the words of the Boston ERISA Law Blog:

So there you have it: if you don’t want to cover the currently rehabilitated participant whose risk of relapse means he can’t go back to work, you better write that down somewhere in the plan or the policy.

via Is the Risk of Relapse a Disabling Condition for Purposes of an LTD Policy? : Boston ERISA Law Blog.

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ERISA – changing the reason for denial not allowed

I came across this interesting ERISA cases.  In both cases, the court held that the claims administrator could just not change the reason for denying the benefits.

In both of these cases, the courts ultimately held that the record and the basis for denying benefits were effectively frozen and could not be changed at a later time.

In Rossi v. Precision Drilling Oilfield Servs. Corp. Employee Benefits Plan, 11-50861 (5th Cir. 2013), the Fifth Circuit Court of Appeals held that the claims administrator was not allowed to change the basis for a denial of benefits during the internal appeal.

Initially, the claims administrator denied the benefits because Rossi was not receiving sufficient medical care to be incurring medical expenses.  During the administrative appeal, however, the claims administrator changed his rationale.  The claims administrator denied the benefits because the plan had an exclusion for inpatient care.  The 5th Circuit Court of Appeals reversed summary judgment and remanded the case.

In Sun Life Health Ins., SACV 11-01516, the District Court for the Central District of California held that the claims administrator was not allowed to deny benefits based on factual investigation during the litigation.

In this case, Sun Life granted short-term disability benefits, but denied the plaintiff long-term disability (LTD) benefits.  Sun Life denied the LTD benefits because plaintiff had failed to satisfy the 180 elimination period, and because plaintiff was not employed at the time the medical evidence supported the disability.

During the litigation, Sun Life identified other facts to support its allegation that the claims should be denied.  As a side note, none of the facts raised during the litigation (which never came up during the investigation or appeal) were reviewed by any doctors.

  • First, Sun Life stated that the denial was supported by the fact that plaintiff “did not seek or receive any treatment” prior to the mental-breakdown event.  Sun Life explained that the treatment that plaintiff received after the mental-breakdown event was not his choice.
  • Second, Sun Life stated that plaintiff was unlikely to be disabled because prior to the mental-breakdown, he had gone on a gambling spree.
  • Third, Sun Life stated that after the mental-breakdown but before the hospitalization of plaintiff, plaintiff “appeared to have lived with his family…without incident.”

The district court did two things.  First, it stated that those rationales were inapplicable because they were not raised before and never reviewed by medical professionals.  Second, the court went through the factual rationales and explained why they were unsupported based on the facts.

 

via Don’t Look Back, Something Might Be Gaining On You: Whether a Plan Administrator Can Raise New Bases For Denying a Claim Beyond Those Raised in the Initial Denial of Benefits : Boston ERISA Law Blog.

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ERISA and “spouse” definition

I bring to your attention Radtke v. Local 638 Health, Welfare, Eye & Dental Fund, 10-cv-4175 (MJD/JJG) (D. Minn. 4/2/2012).  In this case, the Fund terminated the enrollment of Plaintiff based on its interpretation of Minnesota law.  In summary, the Fund obtained information that Plaintiff was a transgendered individual and terminated her benefits.  The District Court disagreed with the Fund’s decision on the basis that the Fund had ignored all evidence of Minnesota’s view of Plaintiff’s sex and marital status.

When Plaintiff was born, Plaintiff’s gender was categorized as male.  Plaintiff was diagnosed with gender dysphoria, in which a patient’s psychological identification of her gender doe snot match the anatomical identification.  The Hennepin County Court granted the name change of Plaintiff to a female name.  Plaintiff also participated in a Transgender Program, and eventually underwent sex-reassignment surgery.  In 2005, Plaintiff filed a Petition for Modification of Birth Record and Issuance of Replacement Birth Certificate, whereby the birth record identified Plaintiff as female.  Later in 2005, Plaintiff married her spouse in Minnesota, and they were issued a marriage license by a Minnesota court.

The District Court determined that Plaintiff is the legal spouse of Mr. Radtke under Minnesota law and therefore an eligible dependent under the Plan.

The Plan was unambiguously written to allow all persons who are legal spouses under Minnesota law to be eligible family dependents.  The Fund’s role was to ascertain Minnesota law.  It was not the Fund’s role to impose its own definitions of gender and marriage upon its participants.  In this case, the Fund ignored all evidence of the State of Minnesota’s view of Plaintiff’s sex and marital status.  The Fund’s decision was not only wrong, under a de novo review, it was a flagrant violation of its duty under any standard of review. 

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