Life, Health, Disability and ERISA Quarterly Cases, Vol. 1

Cases

Download BALMERT v. RELIANCE STANDARD LIFE INSURANCE COMPANY 

Download BARINOVA v. ING 

Download BILEZIKJIAN V. UNUM LIFE INS. CO. OF AMERICA 

Download CAPONE v. AETNA LIFE INSURANCE COMPANY 

Download COUNTRY LIFE INSURANCE COMPANY v. MARKS 

Download CUSSON v. LIBERTY LIFE ASSURANCE COMPANY OF BOSTON 

Download DARVELL v LIFE INSURANCE COMPANY OF NORTH AMERICA 

Download DYER v. HILL SERVICES PLUMBING AND HVAC 

Download FIDELITY NATIONAL TITLE INS. CO v. REGENT ABSTRACT SERVICE, LTD 

Download HALL v.

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Extra-Record Evidence Denied Challenging Substantive Determination.

Richard v. Fleet Financial Group Incorp. LTD Employee Benefit Plan

(2nd Cir., February 24, 2010) 

 

In an ERISA action, plaintiff challenged the denial of her long term disability benefits due to chronic fatigue syndrome.  The Court held that, under a discretionary review, the insurer’s decision to deny benefits was reasonable and supported by substantial evidence.  The objective evidence in the administrative record considered by the Second Circuit included surveillance videos, occupational therapy assessment, independent evaluation, independent review of the claims file and statements

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Accidental Death and Dismemberment Policy Covered Death Caused by Medical Malpractice

Barnes v. Am. Int'l Life Assur. Co(S.D.N.Y., February 4, 2010)

Insured under a group accidental death and dismemberment insurance policy died after a cathe was improperly inserted in her chest, causing cardiac arrest. The insurer denied the claim arguing medical malpractice did not coverage medical malpractice and that her death was the result of sickness or disease. The district court in New York held that the insured's death was unintentional and unexpected and, therefore, an accident entitling the surviving spouse to benefits under

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Eleventh Circuit Court Reversed Lower Court Holding In Favor Of Insurer On Denial Of ERISA Claims

Capone v. Aetna Life Ins. Co.

(United States Court Of Appeals, Eleventh Circuit, January 5, 2010)

 

This action arises out of a diving accident wherein policyholder struck his head on the bottom of the ocean while diving in the Bahamas, paralyzing himself from the neck down.  Policyholder sought benefits under the Accidental Death and Personal Loss provision of his employee health insurance policy administered by Aetna.  Aetna denied the policyholder’s claim for benefits and the district court granted Aetna’s motion for summary

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Disability Benefits Administrator Did Not Abuse Discretion By Affirming Denial Of Short-term Benefits Prior To Receipt Of Additional Data Requested From The Claimant’s Treating Physician

Medina v. Metro. Life Ins. Co

(1st. Cir. (P.R.) November 24, 2009)

 

The claimant's short-term disability benefits were terminated, and upon the claimant's appeal, sent out for independent review.  After the reviewing physician's report was received, the administrator provided the report to the claimant's treating physician, and requested additional information.  The claimant was on notice that such information was requested.  The treating physician never responded.  The administrator, based upon the independent evaluation, re-affirmed its denial of disability benefits.  The claimant sued, asserting that the administrator

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Eleventh Circuit Affirms Insurer’s Interpretation Of Policy Language In A Cancer And Special Disease Policy Regarding the Meaning Of “Actual Charges Incurred”

Philadelphia American Life Ins. Co. v. Buckles

(United States Court of Appeals, Eleventh Circuit, October 23, 2009)

 

This case involved the interpretation of a provision in a supplemental cancer and specified disease insurance policy.  The district court held that the term “actual charges incurred” is unambiguous and “means the actual amount accepted by a health care provider as full satisfaction of the policyholder’s obligations for treatment covered by the policy.”  The policyholder contended rather that “actual charges incurred” is synonymous with “actual

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California Passes Critical Life Insurance Bill

California became the 34th state to regulate life settlements when Gov. Arnold Schwarzenegger of California signed Bill S.B. 98.  The bill preserves a policyholder’s right to sell the life insurance policy for value prior to lapse or surrender.  Additionally, individuals can obtain life settlements through an agent, an prohibit insurance companies from restricting life insurance agents from informing policyholders about such settlements.  The law provides stronger consumer-orientated provisions, including licensing mandates for brokers and settlement companies, requiring disclosures regarding offers, business relationships and compensation,

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Seventh Circuit Applies “Arbitrary and Capricious” Standard of Review of Long Term Disability Plan

Black v. Long Term Disability Insurance

(7th Cir. [ Wis.] September 18, 2009)

After being denied coverage under her employer’s long term disability plan, an employee filed an ERISA action for benefits.  The employee argued that the court should review the matter under a de novo standard.  The Seventh Circuit held that the benefits determination was subject to an arbitrary and capricious standard of review rather than de novo because the plan grants the insurer discretion in its benefits determinations. 

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Conflict of Interest Insufficient to Warrant De Novo Review, Denial of Benefits Upheld

Hobson v. Metropolitan Life Ins. Co.

(2nd Cir., July 29, 2009)

 

The Second Circuit rejected plaintiff’s argument that a de novo review was warranted given the administrator’s structural conflict of interest.  In the wake of MetLife v. Glenn, the court acknowledge that a conflict is created by an administrator’s ability to both determine eligibility and pay benefits, but found there was no evidence suggesting the administrator’s decision was influenced by the conflict and, therefore, afforded it no weight. 

 

Under

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The D.C. Circuit Court Requires the SEC to take a Second Look at its Regulation of Fixed Index Annuities

American Equity Investments v. SEC (D.C. Cir., July 21, 2009)

As any savvy investor knows, “annuity contracts” or “optional annuity contracts” that are the subject of State regulations are exempt from the Securities Act of 1993. See American Equity Investment Life Ins. Co. v. Securities Exchange Comm., Case No: 09-1021 (D.C. 2009). A hybrid annuity termed a “fixed index annuity” combined certain benefits of fixed annuities, along with the earning potential of a security.  Subsequent to their introduction in the mid-1990’the sales volume

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