I’m pleased to report that this week’s notable decision is a Kantor & Kantor victory in the matter of Sangha v. Cigna Life Ins. Co. of New York, No. 17-CV-05158-HSG, __F.Supp.3d__, 2018 WL 3023514 (N.D. Cal. June 18, 2018), involving a termination of long-term disability benefits. Sangha sought long-term disability (“LTD”) benefits relating to chronic pain secondary to cervical degenerative disc disease and C4 to C7 spinal fusion surgery. Under the governing LTD policy, Sangha was entitled to benefits if she is “unable to perform the material duties of any occupation for which he or she may reasonably become qualified based on education, training or experience,” and if “solely due to Injury or Sickness…she is unable to earn more than 60% of…her Indexed Covered Earnings.” Cigna paid Sangha for several years, though during the course of that time it denied her claim on three occasions and required her to go without benefits while she appealed those denials. On its most recent denial, however, after the Social Security Administration found Sangha disabled, and she reimbursed Cigna for overpaid LTD benefits, Cigna refused to reinstate her claim. That is, until now. Continue Reading Firm Victory in Long-Term Disability Dispute Against Cigna Life Insurance Company of New York
Fifth Circuit Rules in Favor of Life Insurance Beneficiary Based on Expert Report Insurer Failed to Disclose During Claims Process
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