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…

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…

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 …

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…

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…

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…

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., __…