In this several-part blog series titled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death and dismemberment and disability claim, from navigating a claim, to handling a claim denial and through preparing a case for litigation.  In Part Eight of this series, we discuss the impact of a finding of disability by the Social Security Administration (“SSA”) on a claim for disability benefits that was filed under an insurance policy governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). Social Securi ..read more

ERISA requires that an administrator provide a claimant with a “full and fair” review if a denial decision is made.  It has long been held that an administrator must provide a claimant with copies of internal medical reports it generated and relied upon when making its decision to deny a claim, but when do these internal medical reports need to be disclosed?  This question was addressed in the recent decision, Wagenstein v. Cigna Life Insurance Co., 2020 WL 68394 (9th Cir. Jan. 7, 2020) (“Wagenstein”).  The Ninth Circuit held in Wagenstein that when an administrator “has engaged in a procedura ..read more

Most ERISA lawsuits proceed in Federal court. ERISA plaintiffs are not entitled to jury trials.  Instead, ERISA lawsuits are resolved in bench trials based upon the administrative record.  The facts contained in the administrative records are gathered during the claim review process and the administrative appeal before the lawsuit is filed.  An extremely important component of any administrative record are the plaintiff’s medical records. Insurance companies that fund employer provided benefit plans have financial incentives to deny meritorious claims.  In many cases, they will retain experts ..read more

Life insurance lapse generally refers to coverage ending for insufficient or nonpayment of policy premiums. If premiums are not paid during the grace period to sustain the policy, then the life insurance ends.  The lapse of a life insurance policy at the wrong time could have disastrous consequences for persons or families because policyholders could easily lose their life insurance if a single premium is accidentally missed, even if they have been paying premiums on time for years. On January 1, 2013, California added new sections 10113.71 and 10113.72 to the Insurance Code, as a way of provi ..read more

Under insurance policies governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), when an insurer denies a person’s claim for life insurance benefits, short-term-disability benefits or long-term-disability benefits, the beneficiary must request that the insurance company review the denial or termination if they intend to sue the insurer to obtain their benefits.  Courts refer to this review as an “administrative appeal” and the obligation to pursue that appeal as the duty to exhaust administrative remedies.  Courts have universally concluded that they “have the authority to e ..read more

In the November 19, 2019 issue of the Los Angeles Daily Journal, the Daily Journal published an article written by the McKennon Law Group PC’s Robert J. McKennon.  The article addresses a previous 2009 Daily Journal investigation that revealed insurers’ regular practice of improperly denying claims.  Since 2009, recent regulations promulgated by the Department of Labor and recent court opinions have helped even the playing field for claimants.  A full and fair review of a claim for benefits is required by statute and regulation, and helps prevent insurers from illicit claim denials as detailed ..read more

In this several-part blog series titled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death and dismemberment and disability claim, from navigating a claim, to handling a claim denial and through preparing a case for litigation.  In Part Seven of this series, we discuss the full and fair review required under the Employee Retirement Income Security Act (“ERISA”), in contrast with the usual practices and power imbalance insurers employ to deny claims.  Our focus in this article will be mostly on disability insuranc ..read more

In this several-part blog series titled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death and dismemberment and disability claim, from navigating a claim, to handling a claim denial and through preparing a case for litigation.  In Part Six of this series, we discuss Independent Medical Evaluations and Peer Reviews.  Our focus in this article will be mostly on disability insurance claim denials. When an insurer examines a disability claim or appeal, it has the medical records examined by medical evaluators, typic ..read more

In the August 28, 2019 issue of the Los Angeles Daily Journal, the Daily Journal published an article written by the McKennon Law Group PC’s Robert J. McKennon.  The article addresses a recent case by the Ninth Circuit Court of Appeals, Dorman v. Charles Schwab, which overruled the Ninth Circuit precedent Amaro v. Continental Can Co. and enforced an arbitration clause in a pension plan on the basis that Supreme Court precedent had impliedly overruled its opinion in Amaro.  Given the expansive reading of arbitration clauses by the Supreme Court and now the Ninth Circuit, it is likely that more ..read more

Ordinarily, a participant or beneficiary of a plan governed by the Employee Retirement Income Security Act of 1974 (“ERISA”) must avail himself or herself of the plan’s internal review procedures before bringing a civil action in federal court for recovery of plan benefits.  This includes group ERISA plans offering long-term disability, life, health or accidental death benefits.  Although ERISA does not explicitly require exhaustion of administrative remedies, federal courts have held that an ERISA plan participant must exhaust the plan’s administrative appeal procedure before filing a federal ..read more