We conclude our blog series on best practices in administering benefit claims with the three C’s: be clear, be consistent, and communicate. The key to effective benefit claim administration ultimately boils down to drafting and maintaining clear plan documents, implementing and enforcing plan terms consistently, and communicating clearly with plan participants and beneficiaries. First, all … Continue Reading
As we shifted focus last week from a plan’s administrative claims procedures to defending against a claim for benefits in court, we explained how a well-documented administrative record can enhance the chances of getting a case dismissed at the outset without the need for protracted litigation. This week, we offer three opportunities to further manage … Continue Reading
Up to now, our blog series has focused on best practices for implementing a plan’s claims and appeals procedure. We shift gears this week to see how following these best practices pays dividends if a participant’s (or beneficiary’s) claim is denied and the participant decides to pursue the claim for benefits in court (or, if … Continue Reading
When a plan administrator is attending to a benefit claim and thinks it is time to call in an attorney, are those discussions privileged and protected from disclosure to claimants? In this week’s blog, we take a look at some of those communications between attorneys and plan administrators and examine whether or not they are … Continue Reading
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
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
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
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
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
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
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 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
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
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, 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
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
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
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
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
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
The Eighth Circuit held that the named beneficiary of an ERISA governed life insurance policy was entitled to the proceeds even though the decedent’s will named a different beneficiary. Hall v. Metro. Life Ins. Co., 2014 U.S. App. LEXIS 8652 (8th Cir. May 8, 2014). Dennis Hall, the decedent, obtained a life insurance policy issued … Continue Reading
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
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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