Courts strive to enforce the terms of benefit plans in order to ensure their efficient operation.However, there are times when the provisions of benefit plans make no sense under the circumstances; and Waskiewicz v. Unicare Life and Health Ins. Co., 2015 WL 5751585 (6th Cir. October 2, 2015) illustrates one of those circumstances. 

In Waskiewicz, a product design engineer for Fort Motor Company was unable to submit a timely claim for disability benefits due to her severe mental illness.  On account of the late submission, Ford’s claim administrator denied the claim, and a federal court upheld that denial.  However, a federal appellate court disagreed and ordered the plan to consider the claim.

The court found: “While [the plaintiff] did not comply with the notification deadlines outlined in Section 4.02 of the Plan, that failure is not surprising given that she was suffering from severe mental illness and was unable to comply due to the very disability for which she sought coverage.”The court thus deemed the denial “inconsistent with the spirit of employer-provided health care benefits generally and with this Plan specifically.” 

Although the court’s opinion was unsupported by citations to precedent, it was well-rooted in logic and common sense. It is encouraging to see a court give recognition to ERISA’s purpose and exercise its power to redress an obvious wrong.

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Update on ERISA-governed insurance benefit claims:  NACLE

Update on ERISA-governed insurance benefit claims: NACLE

ERISA law is constantly changing; and with each new ruling, the scope and context of how issues relating to disability, life and health benefits are resolved by the courts is constantly evolving.  In June of 2021, Mark DeBofsky recorded a continuing legal education program for the National Academy of Continuing Legal Education (NACLE) providing an update on ERISA-governed insurance claims.