An insurance company may waive its right to deny benefits when it accepts premiums for coverage that its policy did not actually provide. It may also waive its right to deny benefits where, even for a short period of time, it provides the very benefits it later seeks to deny…
In an ERISA disability case, a federal district court reviews a decision to deny benefits under “an arbitrary and capricious” standard. Under this standard, a court will not overturn a denial of long-term disability benefits if a plan administrator can offer a “reasoned explanation” for its decision. Simply put, even…
In an ERISA disability lawsuit, the plan administrator’s “denial letter” is one of the most important documents for a plaintiff. The letter is supposed to explain why the plan administrator denied a claim for disability benefits. A denial letter may also describe why the plan administrator rejected an administrative appeal…
Plan administrators will often deny claims for total disability benefits on the basis that the claimant is still able to work. However, under precedent in Tennessee and in the Sixth Circuit, you can hold a full-time job and still qualify for total disability benefits, unless your policy says otherwise. In…
In an ERISA disability case in which a plaintiff is challenging a plan administrator’s denial of long-term disability benefits, a court can do one of three things: (1) It can uphold the plan administrator’s decision; (2) it can reverse the decision and award the plaintiff disability benefits; or, (3) it…
Most ERISA disability plans require claimants to file an administrative appeal of any denial of long-term disability benefits prior to filing a lawsuit. Under Sixth Circuit case law, if you fail to file an administrative appeal (also referred to as failing to exhaust administrative remedies), the court will likely dismiss…
In our firm’s experience, administrators of ERISA plans (“insurers”) are quick to disregard subjective conditions when evaluating individual claims for long-term disability benefits. Although conditions like chronic pain, stress and fatigue can make it impossible for people to work a full-time job, insurers will regularly discount medical evidence that cannot…
When we are retained by a new ERISA disability client, one of the first documents we review is the letter from the plan administrator denying long-term disability benefits, or, as it is most often called, the “denial letter.” Most denial letters, regardless of the disability at issue, follow the same…
In a post from a little over a year ago, we discussed that, if you have an ERISA long-term disability claim, you generally cannot file a lawsuit challenging an insurer’s denial of benefits until you have exhausted your administrative remedies. So, even if the insurer, or plan administrator, denied your…
Nearly all employee benefit plans are governed by the Employee Retirement Income Security Act of 1974, or ERISA. ERISA is a federal law. As a result, claimants who sue their plans for a denial of disability benefits usually will have to try their cases in federal courts. More importantly, in…