This week’s notable decision is White v. Life Insurance Company Of North America, No. 17-30356, __F.3d__, 2018 WL 2978641 (5th Cir. June 13, 2018), a dispute over life insurance benefits based on the application of an exclusion for death caused by intoxication or drug abuse. What’s interesting about this case is that the insurance company had discretion to decide claims and it was a close call based on the evidence. Ordinarily, when the evidence presents a close call, a court will uphold the administrator’s decision, especially under abuse of discretion review. But in this case, the Fifth Circuit was troubled that LINA withheld an expert report that it commissioned during the claims process and violated ERISA Regulations by failing to disclose the report to the beneficiary. This fact appeared to tip the scale in favor of the beneficiary. The message to insurance companies should be loud and clear: It doesn’t pay to hide the ball.
Continue Reading Fifth Circuit Rules in Favor of Life Insurance Beneficiary Based on Expert Report Insurer Failed to Disclose During Claims Process
Ninth Circuit Holds that Parity Act Requires Health Plan to Also Provide Room and Board Coverage for Residential Treatment Facilities
This week’s notable decision is out of the Ninth Circuit Court of Appeals in the matter of Danny P. v. Catholic Health Initiatives, No. 16-35609, __F.3d__, 2018 WL 2709733 (9th Cir. June 6, 2018). Plaintiffs brought suit against Catholic Health Initiatives and Catholic Health Initiatives Medical Plan–Blue Cross Blue Shield (collectively “the Plan”) for denying the cost of Nicole B’s inpatient stay in Island View Residential Treatment Center, a residential mental health treatment facility. The district court granted summary judgment in favor of the Plan. It found that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, codified at 29 U.S.C. § 1185a (“Parity Act”) did not require that the Plan’s coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities.
Continue Reading Ninth Circuit Holds that Parity Act Requires Health Plan to Also Provide Room and Board Coverage for Residential Treatment Facilities
Premature Denial of Long-Term Disability Benefit Claim Mitigates Claimant’s Failure to Exhaust Administrative Remedies
This week’s notable decision is a Ninth Circuit decision in the matter of Cuaresma, Jr. v. Farmers Group Disability Income Plan, et al., No. 16-16946, __F.App’x__, 2018 WL 2439529 (9th Cir. May 31, 2018). Although it is an unpublished decision, the fact pattern is a novel one and it presents a good roadmap for how an unwary claimant can get around the strictly applied exhaustion requirement.
In this case, Liberty Life denied Plaintiff’s claim for long-term disability (“LTD”) benefits prior to the expiration of his time to provide proof of claim and a date earlier than the date Liberty Life told him it would make a decision. Specifically, prior to the end of the policy’s elimination period (while he was receiving short-term disability benefits), Liberty Life wrote to Plaintiff on September 19, 2014 and advised him that it would begin reviewing his LTD benefit claim. Liberty Life gave Plaintiff until November 2, 2014 to return claim forms and submit medical records.
Continue Reading Premature Denial of Long-Term Disability Benefit Claim Mitigates Claimant’s Failure to Exhaust Administrative Remedies