You already know that the final battleground in lawsuits seeking ERISA-governed long term disability (LTD) benefits is whether a prevailing plaintiff should be awarded prevailing party attorney fees. Should plaintiffs always recover attorney fees when the ultimate decision to deny benefits “was a close call” …and both sides’ positions had merit? No.  And this new case explains the point. There is no guarantee that a prevailing plaintiff should be awarded fees, even when a court awards benefits in a plaintiff’s favor. This is especially true when the decision to deny benefits is well suppo ..read more

You know that the ERISA regulations set out claims procedural requirements. Whether the claims administrator complied with the claims procedure requirements is often a key battleground when a court is determining if the long term disability claim was improperly denied. This new case highlights the arguments Plaintiffs’ may make in challenging claims handling, and how the Sixth Circuit rejected those arguments. Avery v. Sedgwick Claims Management Services, Inc. and FCA US LLC Long Term Disability Benefit Plan, 2023 WL 4703865 (6th Circuit July 24, 2023)(Applying abuse of discretion standard of ..read more

You already know that the Elimination Period in long term disability cases is a key focus in assessing eligibility for benefits. This new Sixth Circuit case explains: the very high burden of proof a Plaintiff must meet to establish “continuous” disability during the Elimination Period; and when medical evidence obtained after the Elimination Period cannot satisfy the Plaintiff’s burden to prove disability during the Elimination Period. Tranbarger v. Lincoln Life & Annuity Co. of New York, ___ F.4th __, 2023 WL 3527418 (6th Cir. May 18, 2023) (Affirming denial of benefits the Court held ..read more

As you know, the federal circuits have varying approaches to resolving ERISA denial-of-benefit cases. Some circuits use Rule 56 summary judgment as a process to resolve these cases, while the trend has been to use Rule 52 bench trials to resolve cases. A new case highlights that, in cases applying de novo review, Rule 52 bench trials should be used–especially when there are factual debates on the diagnosis or severity of impairment of a claimant.   And…how much weight should be given to independent reviews by physicians “who only review the paper record”?  This new case highlights th ..read more

Can a district court consider new arguments justifying claim denial that were not articulated in the initial claim denial or appeal? NO.  In fact this new Ninth Circuit decision indicates for the first time that it is “clear error” for a district court  to adopt “newly presented rationale when applying de novo review.” Even rationale focused on a claimant’s credibility must be affirmatively stated in the claim denial, if considered, or it will be deemed a “newly presented rationale” and must be excluded from consideration by the district court if asserted in the litigation. Here’s th ..read more

Can a district court consider new arguments justifying claim denial that were not articulated in the initial claim denial or appeal? NO. In fact this new Ninth Circuit decision indicates for the first time that it is “clear error” for a district court to adopt “newly presented rationale when applying de novo review.” Even rationale focused on a claimant’s credibility must be affirmatively stated in the claim denial, if considered, or it will be deemed a “newly presented rationale” and must be excluded from consideration by the district court if asserted in the litigation. Here’s the newest cas ..read more

Can the ERISA claims administrator “cure” inadequacies, made during its initial claim denial, during the appeal process? Yes. Did a claims administrator’s recommendation, that a claimant receive a job-accommodation, constitute sufficient proof of disability?  No. This new case highlights these issues: Canter v. AT&T Umbrella Benefit Plan No. 3, 33 F. 4th 949 (7th Cir. May 11, 2022)(Errors made during the initial claim denial can be “cured” during the administrative appeal; “[D]isability-benefit and job-accommodation determinations may resemble each other, but they are not identical, a ..read more

Sometimes an ERISA-governed disability benefit claim is denied on a specific issue that precludes the need for a full development of the record on the merits of the claim. E.g., claimant was not eligible for benefits because he was not a full-time employee at the time of disability. But when should courts order remand, after determining the claimant may be eligible for benefits?  This new decision provides some helpful guidance. Here’s the case of Newsom v. Reliance Standard Life Ins. Co., 2022 WL 500403, __ F.4th __ (5th Cir. February 18, 2022)(“‘[I]t is unnecessary for plans to hedge th ..read more

What is the most efficient way to invite the district court to resolve ERISA-benefit claims? What’s the difference between using Rule 56 motions for summary judgment, versus a Rule 52 Motion for Judgment? This new case highlights why Rule 52 motions may be the preferred motion to efficiently resolve ERISA benefit claims.  Avenoso v. Reliance Standard Life Insurance Company, __ F.4th __, 2021 WL 5570816 (8th Cir. November 30, 2021)(“‘[S]ummary judgment is inappropriate when the record permits reasonable minds to draw conflicting inferences about a material fact.’” “Parties that wish the di ..read more

What happens when an ERISA-governed disability claim is denied solely under the “own occupation” provision, but a reviewing district court concludes the claimant is entitled to “own” occupation benefits? Does an insurer “waive” an evaluation of the “any occupation” provision because the insurer denied the claim solely on the “own occupation” standard? NO. Can the district court evaluate and award continued benefits under the “any occupation” standard when the insurer has not yet made that assessment?  NO. Here’s the recent case of Martinez v. Standard Ins. Co., 2021 WL 4592430 (5th Cir. O ..read more