The Fifth Circuit concluded that a plan’s three-year contractual limitations period began to accrue when a beneficiary received a letter in 2008 that prominently displayed on the first page the monthly earnings used to calculate his long term disability benefits. The Court held that the claim was time-barred because the beneficiary failed to bring his … Continue Reading
The Tenth Circuit upheld a claims administrator’s decision denying a claim for residential mental health treatment as not medically necessary. In so holding, the Court rejected plaintiff’s argument that the claims administrator’s refusal to produce data on its historical denial rates for mental health treatment warranted a de novo review because that information was not … Continue Reading
The First Circuit held that a plaintiff failed to timely exhaust her administrative remedies under a long-term disability plan because the plan’s 180-day time limit for submitting appeals commenced on the date the plaintiff received notice of the decision that it was going to terminate her long-term disability benefits, not the actual date her benefits … Continue Reading
The Second Circuit held that plaintiffs’ allegations that the defendant suffered from a “categorical potential conflict of interest”—because it both funded the plan and was the claim’s decision-maker—did not affect the application of the arbitrary and capricious standard of review in the absence of a showing by the plaintiffs that the conflict actually affected the … Continue Reading
The Seventh Circuit rejected a disability plan participant’s argument that an untimely decision denying his claim for long-term disability benefits warranted changing the standard of review from arbitrary and capricious to de novo. In so ruling, the Court explained that had plaintiff filed suit once the time for a timely decision had passed (because his … Continue Reading
A federal district court in New Jersey held that supplemental documentation submitted by a participant in connection with the claims review process did not restart the clock for a claims administrator to decide the participant’s appeal. Plaintiff Tracee Lewis-Burroughs timely appealed Prudential Insurance Company of America’s decision to stop paying her long-term disability benefits.… Continue Reading
The Third Circuit held that a plan administrator’s plan interpretation requiring an actuarial reduction of certain employees’ pension benefits conflicted with the plan’s terms. As such, its decision to reduce participants’ benefits violated ERISA section 502(a)(1)(B), and also violated ERISA’s prohibition against cutbacks of accrued benefits. … Continue Reading
The Ninth Circuit held that a plan administrator’s failure to render a decision on a long-term disability benefits claim within the period mandated by the plan and ERISA did not alter the standard of review that the court should apply to the plan fiduciary’s decision concerning the claim. Plaintiff Isela Dimery received long-term disability benefits … Continue Reading
The Ninth Circuit recently held that where an ERISA plan provides the plan administrator discretionary authority to determine benefit claims, procedural violations that occur during the course of the administrative claims process “do not alter the standard of review unless those violations are so flagrant as to alter the substantive relationship between the employer and … Continue Reading
A federal district court in New Jersey granted summary judgment in favor of New Jersey Bac Health Fund, finding the limitations provision set forth in the Fund’s SPD to be reasonable. Barriero v. NJ Bac Health Fund, 2013 U.S. Dist. LEXIS 181277 (D.N.J. Dec. 27, 2013). Under the welfare plan limitations provision, participants seeking to … Continue Reading
