Articles Posted in ERISA

Dr. Ghandi Gutta filed a claim for Long Term Disability Insurance when he was no longer able to continue his practice as a laparoscopic surgeon due to multiple medical conditions. When his definition of disability changed to “any occupation” at the end of two years his insurer, Standard Select, terminated his benefits contending that, even with his multiple medical conditions, he was able to work in the medical field.

Utilizing the the arbitrary and capricious standard of review, the court accepeted the insurer’s argument that Dr. Gutti failed to provide persuasive evidence that he was unable to perform other work in the medical field and that he had the skills necessary to work as a medical director or assistant medical director. To make matters worse, the court also ordered Dr. Gutti to repay $74,000 in overpayments as a result of payments he recieved under a different disability policy.

This case illustrates how difficult it can be for claimaints to obtain benefits that are governed by ERISA.

A Louisiana court recently rejected a long term disability insurer’s attempts to hide behind the protections afforded insurance companies by ERISA. In Gulf Coast Plastic Surgery v Standard Insurance Co. the Court determined that a claim that the insurance agent failed to increase the policy limits despite the doctors request and the agent’s promise was not preempted by ERISA. Rather, it was a simple negligence claim, even though it involved an ERISA policy.

The Court found that the claims against Hillyer(the insurance agent) were not subject to preemption under ERISA, because they did not implicate a relationship governed by ERISA and because the resolution of the claims does not require interpreting an ERISA plan. THe insurance agent was not an ERISA fiduciary, and the resolution of such allegations did not require the interpretation of an ERISA plan.

At least they weren’t ranked as the worst insurance company for consumers. (That award goes to Allstate.) Long Term Disability Insurer-Unum was ranked second from worst in a recent study cited by the SunHerald.com. Despite agreeing to pay a massive fine and review thousands of its Long Term Disability claims decisions in a Multi-State Regulatory Settlement Agreement, Unum was still ranked near the absolute bottom of insurers.

According to the article Unum earned a profit in 2007 of more than 679 million dollars while paying its CEO a whopping 7.3 million dollars. Unum was joined in the study by Allstate, AIG, State Farm and Conseco as the most anti-consumer insurance companies in the U.S.

On June 19 the Supreme Court issued its much anticipated decision in Metlife v Glenn regarding the conflict of interest created by a long term disability insurer who both determines whether an insured is eligible for benefits and pays benefits out of its own pockets.

Justice Breyer authored the majority opinion confirming that when a plan administrator both evaluates claims for benefits and pays those benefits a conflict of interest is created which requires the reviewing court to weigh that conflict as a factor in determining whether there was an abuse of discretion.

The majority opinion reaffirms the principles first identified in the Firestone decision. Any practitioners who were hoping this decision might change the landscape are sure to be dissapointed as the Court specfically recognized that it was not providing any detailed set of instructions on determining the effect of the insurer’s conflict on its ultimate decision to deny benefits.

Recently, the US District Court (Judge Richard Enslen) upheld the Michigan Insurance Commissioner’s right to prevent any Long Term Disability Insurer from including discretionary clauses in their insurance contracts in the case American Council of Life Insurer’s v Waters.

This could be a tremendously important decision for anyone with a long term disability claim. For years now the insurance companies have included clauses giving themselves the discretionary authority to interpret and enforce the provisions of their own insurance policies. The natural result of this power grab was to restrict the Court’s ability to review the appropriateness of the insurance companies decisions. As a result countless otherwise meritorious claims were denied. The insurance companies racked up huge profits while the individuals who filed claims lost their homes and were forced into poverty.

It remains to be seen whether this well reasoned decision is upheld on appeal. The AARP filed an amicus brief in support of the Michigan Insurance Commissioner.