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ERISA: When Can Plan Administrators Get Into Trouble by Deciding a Disability Claim Too Quickly?

By Mike Reilly on August 20, 2019

ERISA plan administrators are constantly pressured by claimants to render decisions quickly…. This is especially true with short term disability claims. You already know that ERISA regulations require that disability claim benefit decisions be made “within a reasonable time but not later than 45 days after receipt of the claim.” 29 CFR § 2560.503-1. This period may be extended “for up to 30 days” twice, under certain circumstances. So, what does “within a reasonable time…

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ERISA: “I Only Missed It By That Much” — Why the “Substantial Compliance” Doctrine May NOT Excuse Late-Issued Benefit Decisions Anymore

By Mike Reilly on July 22, 2019

You already know that ERISA regulations set specific timelines for the issuance of ERISA-governed long term disability decisions. See, e.g., 29 C.F.R. 2560.503-1(i)(1)(i) (45 days for disability claims and 60 days for others). In special circumstances, the administrator can extend the time by which benefit decisions are made. An administrator’s failure to issue benefit decisions can have consequences: in those situations a claimant shall be deemed to have exhausted administrative remedies (and can sue), and…

Boom: The ERISA Law Blog

ERISA (5th Circuit): COLD TRUTH – New Case Gives Critical Guidance on What You Should Know About the Term “Regular Occupation”

By Mike Reilly on June 5, 2019

What does it mean to be totally disabled from the “regular occupation”? Is “regular occupation” defined as the duties the claimant is actually doing in his or her specific job? NO. Each claim should be assessed from the perspective of duties of the job generally in the national economy and not how the job is “performed for a specific employer or in a specific locale.” Here’s the case of Nichols v. Reliance Standard Life Insurance …

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ERISA: Defeating Motions to Compel Discovery Related to Medical Review Experts

By Mike Reilly on May 15, 2019

Disability claimants often attack the ERISA plan’s expert medical reviewer as biased, sometimes seeking discovery in an attempt to show bias. Here’s a new case that highlights what can happen in a de novo review case: No discovery about a medical expert allowed. Shaikh v. Aetna Life Ins. Co., 2019 WL 1571876 (N.D. Cal. April 11, 2019)(In de novo review case, the Court denied discovery related to alleged bias of medical reviewers). FACTS: Plaintiff…

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ERISA (5th Circuit): When An Attorney’s Headaches Are Not Disabling

By Mike Reilly on April 29, 2019

Practicing law can create real headaches. But do headaches constitute a disabling condition justifying ERISA-governed long term disability benefits? This new case explains the correct process in assessing “job duties” in the “Own Occupation” analysis… Foster v. Principal Life Ins. Co., 920 F. 3d 298 (5th Circuit April 4, 2019)(Benefit denial when based on “passing references” to the claimant’s ‘own occupation’ or ‘own sedentary level occupation’ when “unaccompanied by any attempt to articulate…

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ERISA — 8th Circuit: When Malingering Justifies Disability Claim Denial

By Mike Reilly on March 25, 2019

When does evidence of malingering justify denial of a long term disability claim? It depends. A physician’s subjective opinion regarding malingering may have less weight than objective neuropsychological testing. Key Take Away: When the claimant’s neuropsychological testing is rendered invalid due to “failed validity tests,” that may be enough to deny the claim. It is important that the record contain evidence how the tests were conducted, and how the tests objectively measured validity. Here’s the…

Boom: The ERISA Law Blog

ERISA: 1st Circuit – Can a Claimant Save an Untimely Administrative Appeal by Arguing the “Substantial Compliance” Doctrine?

By Mike Reilly on February 28, 2019

You already know that ERISA sets forth a 180-day time limit for internal administrative appeals of benefit denials. And failure to pursue a timely internal administrative appeal can subject the claimant (in a later federal lawsuit) to the defense of failure to exhaust administrative remedies. But can a claimant save an untimely administrative appeal by arguing the “substantial compliance doctrine”? No. Here’s the case of Fortier v. Hartford Life and Acc. Ins. Co., __…

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ERISA: Can a Claimant Seek a Declaration Regarding Future Benefits?

By Mike Reilly on February 20, 2019

From time to time you may see ERISA benefit claimants seeking declarations from the Court regarding “future benefits.” But there is that old rule, recently recognized again, that such claims should be dismissed because there is no “live case or controversy.” To highlight this point, here’s the recent case of Peer v. Liberty Life Assurance Co.., __ Fed. Appx. __ (11th Cir. February 8, 2019)(“Absent an adverse benefits determination, there is no ripe…

Boom: The ERISA Law Blog

ERISA and Awards of Attorney Fees: So What Does “Some Degree of Success on the Merits” Really Mean?

By Mike Reilly on February 6, 2019

You already know that in ERISA cases the court has discretion to award reasonable attorney fees if the claimant shows “some degree of success on the merits” and this success is more than ‘trivial success on the merits’ or ‘purely procedural.’” So, what happens when the Court remands the claim for further consideration by the administrator, and on remand the claim is still denied? Is the Claimant still entitled to attorney fees, even though the…

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ERISA: How Abuse of Discretion Standard Wins Arguments About Ambiguous Contract Terms

By Mike Reilly on February 5, 2019

A common battle ground in ERISA claims involves the argument that ambiguous terms should be construed against the party that drafted the document. This is known as the doctrine of contra proferentem. See generally E. Erlich, [How to] Conquer Your Enemies and Impress Your Friends with Everyday Latin (2010). But when the ERISA Plan has vested discretionary authority to the plan administrator to determine eligibility and construe plan terms, should the court construe ambiguous terms…

Boom: The ERISA Law Blog

Blog Authors

ERISA: When Can Plan Administrators Get Into Trouble by Deciding a Disability Claim Too Quickly?

ERISA: “I Only Missed It By That Much” — Why the “Substantial Compliance” Doctrine May NOT Excuse Late-Issued Benefit Decisions Anymore

ERISA (5th Circuit): COLD TRUTH – New Case Gives Critical Guidance on What You Should Know About the Term “Regular Occupation”

ERISA: Defeating Motions to Compel Discovery Related to Medical Review Experts

ERISA (5th Circuit): When An Attorney’s Headaches Are Not Disabling

ERISA — 8th Circuit: When Malingering Justifies Disability Claim Denial

ERISA: 1st Circuit – Can a Claimant Save an Untimely Administrative Appeal by Arguing the “Substantial Compliance” Doctrine?

ERISA: Can a Claimant Seek a Declaration Regarding Future Benefits?

ERISA and Awards of Attorney Fees: So What Does “Some Degree of Success on the Merits” Really Mean?

ERISA: How Abuse of Discretion Standard Wins Arguments About Ambiguous Contract Terms

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