Benefits Bryan Cave

Benefits BCLP

Long-term disability

Main Content

4 Steps for Compliance with the New Disability Claims Procedures

January 16, 2018

Authors

Meredith Jacobowitz and Lisa Van Fleet

4 Steps for Compliance with the New Disability Claims Procedures

January 16, 2018

by: Meredith Jacobowitz and Lisa Van Fleet

Did you read our post “Work Now, Party Later,” advising you to do just that in response to the new Department of Labor rule governing disability claims procedures? If so—party on! If not, we hope you enjoyed your holiday celebrations, because it is now time to work.

On January 5, the Department of Labor announced its decision that the new disability claims procedure rules will take effect on April 1 of this year. Here is our suggested plan of attack for employers:

Step 1: Review our previous blog post to familiarize yourself with the new rules.

Step 2: Identify which of your plans offer disability benefits.

Remember to check both your ERISA qualified and nonqualified plans.

Step 3. Determine whether you need to amend your plan and/or SPD.

Under the new rules, participants who file a disability claim must receive an expanded explanation of their adverse

Read More

DOL’s Proposed Amendments to the Claims Procedure For Plans Providing Disability Benefits

December 8, 2015

Authors

benefitsbclp

DOL’s Proposed Amendments to the Claims Procedure For Plans Providing Disability Benefits

December 8, 2015

by: benefitsbclp

Recently, the DOL released proposed amendments to the current procedural rules for employees claiming disability benefits under an ERISA plan. The proposed rules enhance existing procedures, mirror the procedural protections for claimants contained in the PHS 2719 Final Rule, and update the ERISA claims procedures (set forth in ERISA Section 503) to align with these standards.

Summaries of the major provisions follow:

  • Independence and Impartiality – avoiding conflicts of interest. All claims must be adjudicated in a manner which ensures that the persons making the decision are independent and impartial. The proposed rules specify that this independence and impartiality requirement mandates that decisions involving the hiring, compensation, termination, promotion, or similar matters of individuals making claims-related decisions, such as a claims adjudicator or medical experts, cannot be made based on the likelihood that the individual will support the denial of disability benefits.
  •  Enhanced
    Read More

Fourth Circuit: Plan Administrator Must Obtain “Readily Available Information” in Claims Determination

December 30, 2014

Authors

Bard Brockman and Lisa Van Fleet

Fourth Circuit: Plan Administrator Must Obtain “Readily Available Information” in Claims Determination

December 30, 2014

by: Bard Brockman and Lisa Van Fleet

What is a plan administrator’s obligation under ERISA to seek and obtain information potentially relevant to a participant claim where the participant has not provided it? The Fourth Circuit recently provided guidance on that issue in the case of Harrison v. Wells Fargo Bank, N.A. A copy of that opinion is available here.

Nancy Harrison was an online customer service representative for Wells Fargo Bank. In 2011, she underwent a thyroidectomy to remove a large mass that had extended into her chest and which caused chest pain and tracheal compression. She was unable to work and received short-term disability benefits under the Wells Fargo plan. While she was recovering and waiting for a second, more invasive surgery, her husband died unexpectedly, triggering a recurrence of depression and post-traumatic stress disorder (PTSD) related to the death of her children in a house fire a few years before.

Read More

Supreme Court Upholds Enforceability of Plan Limitations Period

December 19, 2013

Authors

Bard Brockman and Lisa Van Fleet

Supreme Court Upholds Enforceability of Plan Limitations Period

December 19, 2013

by: Bard Brockman and Lisa Van Fleet

On December 16th, the Supreme Court issued its opinion in Heimeshoff v. Hartford Life & Accident Ins. Co. – a case involving the tension between: (i) the contractual limitations period in Wal-Mart’s group long-term disability policy, and (ii) the requirement that claimants exhaust their administrative remedies before filing suit for benefits under ERISA.  In an unanimous decision, the Court yet again favored the interests of enforcement of reasonable plan terms over competing policy interests.  A copy of Heimeshoff opinion is available here.

The Facts in Brief.  Ms. Heimeshoff submitted a claim under Wal-Mart’s long-term disability plan, claiming that she suffered from “extreme pain, significant pain, and difficulty in concentration.”  Hartford Life & Accident Insurance, the plan’s claims administrator, denied the claim.  Heimeshoff administratively appealed the claim denial, and Hartford issued its final claim denial on November 26, 2007.  Just shy of three years later, on November 18,

Read More

Eighth Circuit Finds No Abuse of Discretion in Administrator’s Termination of Benefits and Raises Questions Concerning Proper Standard of Review Upon Allegations of “Procedural Irregularities”

August 8, 2012

Authors

Jonathan Potts

Eighth Circuit Finds No Abuse of Discretion in Administrator’s Termination of Benefits and Raises Questions Concerning Proper Standard of Review Upon Allegations of “Procedural Irregularities”

August 8, 2012

by: Jonathan Potts

 In a decision released July 24, 2012, the Eight Circuit affirmed a lower court judgment that a plan administrator committed no abuse of discretion when it terminated an employee’s long-term disability benefits. The case, styled Wade v. Aetna Life Ins. Co., No. 11-3295 (8th Cir. July 24, 2012), involved a Quest Diagnostics, Inc. employee’s challenge to Aetna’s termination of her benefits despite a previous, contrary decision from the Social Security Administration (SSA), coupled with allegations of “serious procedural irregularities.” 

In its decision, the 8th Circuit began by concluding that the district court had reviewed the termination decision under the correct “abuse-of-discretion” standard. Under ERISA, a court’s review of a plan administrator’s denial of benefits considers whether the benefit plan gives the administrator the discretion to determine eligibility for benefits. Here, the plan unequivocally granted Aetna this discretionary authority. Nevertheless, Wade sought de novo review of Aetna’s termination decision by alleging

Read More

Limiting Benefits for Drunk Drivers

September 8, 2011

Authors

benefitsbclp

Limiting Benefits for Drunk Drivers

September 8, 2011

by: benefitsbclp

Should employers include a “drunk driving” benefit exclusion in their death and disability policies? Two recent court cases illustrate that these provisions may determine whether or not an employee is entitled to benefits for injuries that occur while intoxicated.

In Allen v. Standard Insurance Co., an employee was found to be intoxicated when she drove to work, crossed the centerline into oncoming traffic, hit a truck head-on and suffered severe head injuries. Because the long-term disability policy provided by her employer limited benefits for disabilities related to substance abuse, the district court ruled that the employer properly limited her benefits because her disability was caused by a drunk driving accident.

In Thies v. Life Insurance Co. of North America, an employee was found to be intoxicated when he crashed a jet ski and died. His employer-provided life insurance policy did not include a drunk driving benefit exclusion. The district court

Read More
The attorneys of Bryan Cave LLP make this site available to you only for the educational purposes of imparting general information and a general understanding of the law. This site does not offer specific legal advice. Your use of this site does not create an attorney-client relationship between you and Bryan Cave LLP or any of its attorneys. Do not use this site as a substitute for specific legal advice from a licensed attorney. Much of the information on this site is based upon preliminary discussions in the absence of definitive advice or policy statements and therefore may change as soon as more definitive advice is available. Please review our full disclaimer.