Resource Center

The Ninth Circuit recently found the District Court for Northern California improperly reviewed MetLife’s denial of long-term disability benefits for plaintiff Matthew Prichard1. When a disability plan gives the plan administrator discretionary authority to determine a participant’s eligibility for disability benefits, a district court must review the administrator’s decision for abuse of discretion. Otherwise, the district court is required to review a plan administrator’s denial of benefits under the de novo standard of review. The de novo standard of review requires the court to look at the facts from the beginning, without giving any weight to the administrator’s determination. In […]

On March 25, 2015, in an unpublished opinion, the United States Court of Appeals, 6th Circuit, found that Michael Stiso was entitled to a cost of living adjustment with regards to his long-term disability benefit. Mr. Stiso had been receiving long-term disability benefits under his employer’s disability insurance plan and believed he was entitled to a seven percent per year cost-of-living adjustment as described in the long-term disability plan and summary plan description. The Sixth Circuit, in reversing the District Court’s ruling, stated By providing plaintiff with a summary plan description that led plaintiff reasonably to understand that he would […]

In a long running legal battle over an insureds long-term disability benefit, the full Sixth Circuit ruled last week that Daniel Rochow’s estate was not entitled to a disgorgement of profits in relation to benefits due on Mr. Rochow’s behalf. By way of background, Daniel Rochow filed a claim for long-term disability benefits in 2002 with his carrier, the Life Insurance Company of North America (“LINA”). LINA initially denied Mr. Rochow’s claim for disability benefits. Mr. Rochow proceeded to appeal and LINA proceeded to uphold their denial three more times. Finally, in 2004, Mr. Rochow filed suit in the United […]

Sedgwick Claims Management Services, the Plan Administrator for the ERISA-governed Long-Term Disability Plan for employees of Eli Lilly and Company (“Lilly”), terminated former Human Resources Director Cathleen Kennedy’s Long-Term Disability benefits once she entered the “any occupation” definition phase of the disability plan. Ms. Kennedy suffered from fibromyalgia that had been long established through her regular medical care and prior Independent Medical Examination’s performed at the request of the Plan. Following termination of her disability benefits, Ms. Kennedy filed an administrative appeal with Sedgwick for reinstatement of her benefits. As part of the appeal process, Ms. Kennedy underwent an Independent […]

U.S. District Judge Samuel Conti on Monday granted Kaiser leave to amend its answer in an ERISA lawsuit brought by retired cardiothoracic surgeon Thomas Gonda. Dr. Gonda was seeking benefits and damages following termination of his long-term disability benefits. The parties had previously entered into a settlement agreement that Kaiser used as a basis for seeking summary judgment in the present case. Judge Conti previously ruled that Kaiser must amend its complaint if it sought to use the settlement agreement as an affirmative defense. As Courthouse News Service notes: Conti granted Kaiser leave to amend its answer on Monday. “The […]

The November 2014 edition of the Newsletter of the Missouri Physician’s Health Program highlights a recent Vanderbilt study on physician suicide risk. “[The] recent study done by Vanderbilt University of 141 Tennessee physicians evaluated for fitness-for-duty assessments found an “astoundingly” high rate of suicide if the physician was 1) found unfit to practice, 2) was in solo practice, or 3) if he/she was taking benzodiazepines (anti-anxiety drugs).” Associate Professor of Clinical Psychiatry and Medical Director of the Vanderbilt Comprehensive Assessment Program, Reid Finlayson, M.D., said, “Being found unfit for practice means a loss of income, loss of social contact and […]

The 10th Circuit Court of Appeals recently reaffirmed ERISA’s requirements that when your Long Term Disability benefits are denied or terminated, you must follow your plan’s rules for administrative remedies before you can bring suit against your LTD insurance company. ERISA requires LTD insurance carriers to provide you with the opportunity to appeal your claim administratively to the insurance company. ERISA also requires the company to notify you of this right to administratively appeal before you bring suit against the company. Generally, the Summary Plan Description, i.e. the document that summarizes your policy for you, should contain the requirements for […]

Many lawyers may recall being told at some point during law school that they were preparing to enter the profession with the highest rate of substance abuse in the county. Now, the National Law Journal reports that lawyers may “suffer addiction at double the rate of the general population.” The Journal states that the ABA and Hazelden Betty Ford Foundation will begin surveying lawyers about addiction, anxiety, and depression to determine the rates at which lawyers suffer from substance abuse and mental illness. This is the first time this type of data will be gathered since 1990. A 2012 report […]

Mark F. Seltzer, Esq., presented the poster, “Professional Impairment: Licensure and Disability Insurance Issues,” designed to help guide monitors and practitioners. This presentation focused on the complex interaction between factual disability that is a result of injury or sickness — often with a psychiatric and/or addiction component — and the frequently concurrent legal issues a medical professional faces regarding their license to practice. Disability policies require that an insured physician establish that he or she is “factually disabled” and receiving appropriate care in order to be entitled to total or residual/partial benefits. On the other hand, state boards of medicine […]

The 6th Circuit Court of Appeals1 recently reaffirmed that Long-Term Disability insurance carriers are required to notify you of your rights for a review and its time limits when they deny your disability claim. The federal law ERISA provides rules governing claims procedures that Insurers must follow when denying your disability claim. MetLife can’t use its own failure to properly notify an individual of his policy rights to deny his right of judicial review. MetLife’s failure to comply with the ERISA rules requiring notice of the policy provisions allowed the individual to sue MetLife, regardless of the time-limitation clause in […]