Employee Benefits & Executive Compensation Blog

The View from Proskauer on Developments in the World of Employee Benefits, Executive Compensation & ERISA Litigation

Tag Archives: Benefit Claims

Best Practices in Administering Benefit Claims #6 – Distinguishing an Inquiry from a Claim

It’s Week #6, and we have turned the corner in our Top 10 Best Practices in Administering Benefit Claims.  In case you missed any (or all) of the first five best practices, links to each of them appear below.  This week we discuss how to distinguish an inquiry from a claim for benefits. The claims … Continue Reading

Best Practices in Administering Benefit Claims #5 – Establishing (and Following) a Good Claims Process

This week we discuss the importance of establishing good claims procedures and the benefits of following those procedures. A plan’s claims procedures should be spelled out clearly in both the plan document and the summary plan description (where the two documents are not one in the same).  In addition to setting all of the applicable … Continue Reading

Best Practices in Administering Benefit Claims #4 – Know (and Understand) the Law: Full and Fair Review

This week in our blog series on best practices in administering benefit claims, we discuss the importance of knowing and, importantly, understanding the laws governing benefit claim administration. Section 503 of ERISA sets forth the general guidelines for a plan’s claims and appeal procedures.  It requires that a plan provide adequate written notice of the … Continue Reading

Best Practices in Administering Benefit Claims #3 – Dealing with Benefit Assignments

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 … Continue Reading

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 … Continue Reading

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 … Continue Reading

Categorical Conflict of Interest Does Not Alter Standard of Review of Benefit Denials

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

Second Circuit Requires Reevaluation of ERISA Attorney Fee Judgment

The Second Circuit determined that a district court erred when it denied an attorney fee award to an ERISA plaintiff who had sought benefits from a plan. In so ruling, the Second Circuit first concluded the district court incorrectly determined that the plaintiff had not achieved “some success”—a threshold requirement for an ERISA fee award—because … Continue Reading

Third Circuit Deepens Circuit Split Over Test for “Top Hat” Status Under ERISA

A Third Circuit decision, Sikora v. UPMC, 876 F.3d 110 (3d Cir. 2017), deepens a circuit split over whether a participant’s bargaining power is relevant to determining whether a plan qualifies for “top hat” status under ERISA. Plans that qualify for “top hat” status are exempt from ERISA’s eligibility, vesting, funding, and fiduciary requirements. To … Continue Reading

Out-of-Network Physician’s Claim Against Insurer Not Preempted by ERISA

The Second Circuit concluded that a promissory estoppel claim by an out-of-network provider against an insurer was not completely preempted by ERISA and thus remanded the claim to state court for further proceedings. The provider’s claim was predicated on its assertion that the insurer made certain representations about coverage for the insured. The Court held that … Continue Reading

Oregon State Court of Appeals Recognizes Federal Slayer Law

Oregon, like many states, has on its books a “slayer statute,” which generally prohibits a slayer or abuser of a decedent from obtaining benefits by virtue of the death of the decedent.  The parents of Julianne Herinckx sought to enforce the Oregon slayer statute and preclude their daughter’s murderers from receiving life insurance benefits payable … Continue Reading

Plan Administrator’s ERISA Declaratory Judgment Action Dismissed for Lack of Jurisdiction

After a top-hat plan and pension plan denied a participant’s claims and appeals for additional benefits, the plan administrators preemptively filed a declaratory judgment action, seeking a declaration that:  (i) termination of defendant’s employment was not for the purpose of interfering with his ability to attain rights under the plans or ERISA; (ii) the top-hat plan … Continue Reading

First Circuit Reviews Top Hat Plan Benefits Denial for Abuse of Discretion

The First Circuit recently applied an abuse of discretion standard of review to a claim for top hat plan benefits. Plaintiff Robert Niebauer, a former executive of Crane, brought a claim for executive severance plan benefits and a claim under ERISA section 510 for interference with his rights to benefits.  The district court granted summary … Continue Reading

Procedural Errors Don’t Alter Standard of Review In ERISA Claim for Benefits

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

Tenth Circuit Finds Plan Administrator Has No Duty to Inquire into Authenticity of Participant’s Beneficiary Designation

Plaintiff Kristopher Towles, the son of a deceased participant of a life insurance plan, challenged the plan’s decision to pay the life insurance proceeds to the deceased’s husband, contending that the beneficiary form replacing him with the deceased husband had been forged.  After five attempts to state a claim, the district court dismissed the complaint … Continue Reading

A Court’s Review of a Disability Benefit Claim May Hinge on the Meaning “Satisfactory to Us”

Twenty-five years ago, the U.S. Supreme Court ruled that courts should review an ERISA participant’s claim for benefits under a de novo standard of review unless the plan gives the plan fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.  Since then, courts have considered what type of … Continue Reading

District Court Concludes Statute of Limitations Defense Must Be Asserted During Administrative Claims Process

Plan administrators sometimes are confronted with claims that appear untimely, but nevertheless focus solely on the substantive issue raised by the claim. A recent ruling from a federal district court in New Jersey suggests that the failure to address procedural issues may result in a finding that such defenses have been waived. In Becknell v. … Continue Reading

Seventh Circuit: Insurance Companies Are Proper Defendants In Suits For ERISA Benefits

The Seventh Circuit held that a health insurer that makes benefits determinations and pays benefit claims, rather than the health plan itself, is a proper defendant in an action for benefits under ERISA Section 502(a)(1)(B).  In Larson v. United Healthcare Ins. Co., No. 12-1256, 2013 WL 3836236 (7th Cir. July 26, 2013) (unpublished), plan participants … Continue Reading
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