This week’s notable decision is Mickell v. Bert Bell/Pete Rozelle NFL Players Retirement Plan, No. 19-10651, __F.App’x__, 2020 WL 6074329 (11th Cir. Oct. 15, 2020), where the Eleventh Circuit reversed the district court’s determination that an ERISA plan did not abuse its discretion in denying disability benefits. Plaintiff Darren Mickell spent nine years in the NFL as a defensive end in which he sustained countless injuries, including multiple blows to the head. In September 2013, Mickell submitted a claim for permanent and total disability (“PTD”) benefits under the NFL Player Retirement Plan (the “Plan”). The Plan provides that initial decisions are made by an Initial Claims Committee (the “Committee”). Players may appeal the Committee’s decision to the Plan’s six-member board (the “Board”) which reviews the claim de novo. The Plan also provides that a player may be referred to one or more “neutral” physicians whose opinions will be a “substantial factor” in the Board’s decision. Finally, the Board is vested with “full and absolute discretion . . .”
Continue Reading Eleventh Circuit Holds NFL Retirement Plan Abused its Discretion by Failing to Consider Evidence and Combined Effects of Plaintiff’s Impairments
First Circuit Rules in Favor of Harvard Pilgrim Health Care in Dispute Over Denied Residential Treatment Benefits
This week’s notable decision demonstrates the difficulty of overcoming a district court’s de novo review on appeal in an ERISA case. Like many courts deciding mental health benefits under ERISA, the First Circuit concluded: “This case is not an easy one.” Doe v. Harvard Pilgrim Health Care, Inc., No. 19-1879, __F.3d__, 2020 WL 5405367 (1st Cir. Sept. 9, 2020).
The case previously reached the First Circuit in Doe v. Harvard Pilgrim Health Care, Inc., 904 F.3d 1 (1st Cir. 2018) (Doe I) which reversed the district court’s denial of Doe’s motion to expand the administrative record, vacated an order of summary judgment for Harvard Pilgrim, and remanded to the district court.
Following remand, and under a de novo standard of review, the district court agreed with Harvard Pilgrim’s determination that continued residential treatment was not medically necessary. Doe appealed.
Continue Reading First Circuit Rules in Favor of Harvard Pilgrim Health Care in Dispute Over Denied Residential Treatment Benefits
Fifth Circuit Revives Claim Against Humana for Denying Eating Disorder Treatment
Good morning, ERISA Watchers! We have two notable decisions to report again this week, including one that is a firm victory.
Let us start with the good news. The first notable decision, Katherine P. v. Humana Health Plan, Inc., No. 19-50276, __F.3d__, 2020 WL 2479687 (5th Cir. May 14, 2020), revives life into a claim by a young woman seeking mental health benefits for partial hospitalization treatment. Katherine received partial hospitalization treatment in 2012 for multiple mental health disorders including an eating disorder. Humana paid for the first 12 days of partial hospitalization treatment and then denied benefits, claiming such treatment was no longer medically necessary based on two Mihalik Criteria. The parties filed cross-motions for summary judgment and the magistrate judge recommended judgment for Humana. The district court accepted the recommendation. Katherine P. appealed.
Continue Reading Fifth Circuit Revives Claim Against Humana for Denying Eating Disorder Treatment