Our blog series on best practices in administering benefit claims has thus far stressed the importance of knowing and reading the plan document and summary plan description. This week, we take a look at a plan term that has been the subject of frequent dispute in health and welfare benefits claim litigation—interpretation of plan provisions
Benefit Claims
Best Practices in Administering Benefit Claims #2 – Know (and Read) Your SPD
Last week, we kicked off our blog series on the fundamentals of benefit claim administration with an explanation of how important it is to know and read your plan document. The plan document is the legally binding contract that describes each participant’s rights and benefits under the plan. It also guides the legal obligations and…
Best Practices in Administering Benefit Claims #1 – Know (and Read) Your Plan Document
Our ERISA Practice Center blog posts often discuss many complex, and sometimes esoteric, substantive and procedural ERISA issues, as well as related agency guidance and case law. In this new ten-part blog series, however, we take a step away from the complex and esoteric in order to review some of the fundamentals of benefit claim…
Quick Tips for ERISA Plan Administrators When Something Goes Wrong
By Paul M. Hamburger on
In 2010, after nearly two centuries of legal jurisprudence, the U.S. Supreme Court (in Conkright v. Frommert), concluded that “People make mistakes.” The Court even acknowledged that administrators of ERISA plans make mistakes!
So what do you do if you find that someone made a mistake in plan administration? When we work with clients…
Foreign Nationals Don’t Have ERISA Claims
By Kyle Hansen on
A federal district court in Pennsylvania held that it did not have subject matter jurisdiction to hear a claim for disability benefits under an ERISA plan brought by foreign nationals working in the Republic of Kosovo. The court explained that absent an “affirmative intention” of Congress that is “clearly expressed” to give a statute extraterritorial…
Ninth Circuit Concludes Domestic Partner Entitled To Benefits
By Kaitlin Hulbert on
The Ninth Circuit concluded that a plan fiduciary abused its discretion in denying survival benefits to a pension plan participant’s domestic partner. In so ruling, the Court explained that the plan’s choice of law provisions provided that the plan would be governed by California law in a manner consistent with the requirements of the Code…
Categorical Conflict of Interest Does Not Alter Standard of Review of Benefit Denials
By Neil V. Shah on
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…
Plan Participant Waived Remedy for Untimely Benefits Determination
By Benjamin Flaxenburg on
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…
ERISA Participant’s Supplemental Submission Doesn’t Restart Exhaustion Clock
By Madeline Chimento Rea on
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.
Plan Administrator’s “Second Plan Interpretation” Violates Anti-Cutback Rule
By Aaron Feuer on
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.