I love it when I can report a righteous outcome in an ERISA disability case.  I remember when I first read the district court decision in Wagner v. Am. United Life Ins. Co., 2017 WL 4099216 (S.D. Ohio Sept. 15, 2017), I said to myself “are you kidding me?!”  As I previously reported, Wagner was rendered paraplegic in a motorcycle accident as a teenager and went to school and worked for much of his adult life.  In his fifties, he was involved in another motorcycle accident and broke his right femur. 

He stopped working and received long term disability benefits after that time but American United Life Insurance Company (“AUL”), a la its claims administrator, Disability Reinsurance Management Services (“DRMS”), terminated his claim in reliance on surveillance video showing Wagner active and not in pain as well as medical reviewers’ opinions of non-disability.  This happened on month 34 of his claim, just two months before a change in the policy’s definition of disability was to take place.  On de novo review, the district court found in favor of AUL.  The court determined that despite Wagner’s subjective complaints, the surveillance video showed a different reality.  The district court also rejected Wagner’s argument that AUL must prove that he can do the thinking required for his job. Continue Reading Sixth Circuit Reverses Denial of Long Term Disability Benefits to Claimant with Paraplegia

In ERISAland, attorneys’ fees are infrequently awarded to defendants for having to defend themselves in a matter involving a denial of disability benefits.  This week’s notable decision, Hackney v. Allmed Healthcare Management, Inc., No. 3:15-CV-00075-GFVT, 2018 WL 1981902 (E.D. Ky. Apr. 27, 2018), is one of those infrequent and disappointing cases where the court orders an unsuccessful plaintiff to pay the defendant five figures in attorneys’ fees and costs.  And all because the plaintiff pushed the envelope in pursuing a cause of action not generally recognized as available under ERISA. Continue Reading Court Orders Unsuccessful Claimant to Pay Third-Party Administrator’s Attorneys’ Fees in Lawsuit Preempted by ERISA

This week’s notable decision results from a series of unfortunate events.  It also highlights an issue plan administrators and participants should be aware of when there is a switch of group life insurance policies.  In Cole v. American Heritage Life Insurance Company, No. 3:17-CV-494-PPS, 2018 WL 1875632 (N.D. Ind. Apr. 18, 2018), the district court enforced Defendant American Heritage Life Insurance Company’s group life insurance policy’s Suicide Exclusion in order to deny benefits for the life of Plaintiff’s deceased husband.  The Suicide Exclusion limits benefits to the amount of premiums paid if the insured commits suicide within 2 years of the certification date.  In this case, the insured committed suicide on January 2, 2016, one day after the American Heritage policy went into effect on January 1, 2016.  This seems cut and dry, except for one fact:  the insured was covered under the employer’s life insurance group policy offered by a different insurance company, Lincoln National, from January 1, 2014 until January 1, 2016.  That policy did not contain a suicide exclusion. Continue Reading Court Enforces Suicide Exclusion In Group Life Insurance Policy Despite Insured’s Prior Coverage