Entries by J.J. Conway

Idaho Federal Court Rules That Medical Provider’s Appeal On Patient’s Behalf Can Serve To Exhaust Administrative Remedies Under ERISA

The United States District Court for the District of Idaho has ruled that a medical provider, acting pursuant to a pretreatment authorization and assignment of rights, may appeal an adverse benefit determination on the patient’s behalf for purposes of exhaustion under ERISA.   In Abdilnour v. Blue Cross of Idaho Health Service Inc., Case No. 17-00412 […]

ERISA Long-Term Disability Claims: Court Allows Standard Of Review Challenge For Improper Discretionary Delegation

The standard of review in ERISA cases can have a considerable impact on the outcome of a long-term disability claim. As the Supreme Court observed in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989), “the validity of a claim to benefits under an ERISA plan is likely to turn on the interpretation of terms in […]

2018: The Coming ERISA Disability Regulations and A Bit of Good News for Claimants

Insurance companies administering ERISA long-term disability claims may be facing new rules.  In 2012 the U.S. Department of Labor’s ERISA Advisory Council undertook a study on issues relating to managing disability claims in the ERISA administrative review context. The Advisory Council recommended that the USDOL review the current claims regulation and recommend specific updates and […]

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A Lawyer’s Tough Talk on Long Term Disability Insurance Claims

In twenty years of handling employee benefit disputes, I have made a few observations of the ways to keep a long-term disability insurance claim in “approved status” or “open” as insurance companies say. A disability claimant’s medical file should include accurate and documented history of disability and should always be up to date. A disability […]

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Court Rules That ERISA Disability Appeal Requirements Must Appear in Plan to Be Enforced

The United States District Court for the Eastern District of Michigan has held that an insurer must advise a long-term disability claimant of its internal appeal requirement within the actual plan document in order to establish a failure to exhaust defense. In Wallace v. Beaumont Healthcare Employee Welfare Benefit Plan, No. 16-cv-10625 (E.D. Mich. January […]

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Court Recognizes “the Spirit of ERISA” in Long Term Disability Claims

The Sixth Circuit Court of Appeals has cited the “spirit of ERISA” in reversing a district court decision granting summary judgment against an employee pursuing a disability claim.  In Waskiewicz v. Unicare Life & Health Ins. Co., 802 F.3d 851 (6th Cir. 2015) the plaintiff-employee was suffering from mental illness when she was discharged by […]