Does the absence of a definitive diagnosis preclude an award of disability benefits? Courts have resoundingly answered that question in the negative, finding that a diagnosis is less important than findings relating to impairment. Symptoms of fatigue, pain, and compromised cognition can be characteristic of many illnesses that can be difficult to diagnose or treat. […]
What is full-time work? The issue is important because eligibility to receive critical benefits such as health and life insurance is dependent on the employee meeting certain active at work requirements in the applicable benefit plan. A recent ruling from a federal court in California focused on this issue and took […]
The availability of health insurance coverage for treatment of mental health conditions recently took a huge step forward with the entry of judgment by the U.S. District Court for the Northern District of California in Wit v. United Behavioral Health.[1] After the issuance of a ruling in 2019 finding United Behavioral Health, or UBH — a UnitedHealth Group […]
Employee Retirement Income Security Act civil procedure often departs in significant respects from the normal civil procedure utilized uniformly by federal courts in all civil actions in accordance with the Federal Rules of Civil Procedure. One aspect of ERISA civil procedure that is especially questionable despite its near-uniform acceptance by the federal judiciary is the […]
There has been a growing volume of litigation relating to disability benefit claims brought by former professional football players. A recent example is the ruling issued by a federal court in California in Dimry v. Bert Bell/Pete Rozelle NFL Player Retirement Plan, 2020 WL 5526607 (N.D. Cal., Sept. 15). This ruling was the second time the […]
Courts are often stymied by how to conclude Employee Retirement Income Security Act benefit claim litigation, but not U.S. District Judge Fernando Olguin of the U.S. District Court for the Central District of California. In Tam v. First Unum Life Insurance Co. on Sept. 30,[1] the court decisively ruled for the plaintiff, Sandra Tam, in […]
Among the challenges presented by spasmodic dysphonia (SD), qualifying for disability benefits can be both difficult and frustrating. The process is complex, confusing, and extremely difficult to navigate without the assistance of an experienced attorney. Yet despite these challenges, both the Social Security Administration and private disability insurers recognize the impact of SD on the […]
How should federal courts conduct a de novo review of Employee Retirement Income Security Act benefit claims? One approach was delineated by the U.S. Court of Appeals for the Seventh Circuit in 2009 in Krolnik v. Prudential Insurance Company of America.[1] There, the court pronounced the phrase “de novo review” as “misleading” and explained the de novo review standard […]
Are undocumented employees entitled to the same employer-sponsored benefits as their co-workers? According to a recent ruling from the 8th U.S. Circuit Court of Appeals, apparently not. In Avera McKennan v. Meadowvale Dairy Employee Benefit Plan, 2020 WL 5085954 (8th Cir., Aug. 28), the appeals court ruled that a hospital (Avera) was unable to recoup significant […]
The most critical issue in Employee Retirement Income Security Act benefits litigation is the standard of judicial review applied by the courts. Under the deferential arbitrary and capricious standard of review, the court reviews a claim record compiled by the insurance company[1] to determine whether a claim denial was “downright unreasonable”[2] and not merely wrong. Because […]
The Patient Protection and Affordable Care Act[1] made a number of significant changes to health insurance coverage in the U.S. One of the most important provisions of the law, which is also known as Obamacare, was a requirement that patients whose benefits are denied are entitled to independent external review. The implementing regulation[2] requires that […]
There has been a growing number of rulings relating to health insurance denials involving mental health treatment. A recent example is Jamie F v. Unitedhealthcare Insur. Co., 2020 WL 4249200 (N.D. Cal., July 23), which involved a claimant who had a long history of being treated for several mental illnesses including anorexia nervosa, depression, anxiety, obsessive-compulsive […]