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December 2016 Archives

"Claims Procedure for Plans Providing Disability Benefits," 81 FR 92316 (December 19, 2016)

The Employee Benefits Security Administration of the U.S. Department of Labor has issued final regulations published in the Federal Register on December 19, 2016 (81 Fed. Reg. 92316) relating to disability benefit claims governed by ERISA.  Proposed regulations were initially published for comment on November 18, 2015 at 80 Fed.Reg. 72014; and after considering over 100 comments, the proposed regulations were modified into a final form in order to "promote fairness and accuracy in the claims review process and protect participants and beneficiaries in ERISA-covered disability plans by ensuring they receive benefits that otherwise might have been denied by plan administrators in the absence of the fuller protections provided by this final regulation. The final rule also will help alleviate the financial and emotional hardship suffered by many individuals when they are unable to work after becoming disabled and their claims are denied."

Medical complications and accidental death insurance

DeBofsky, Sherman & Casciari, PC recently won an important accidental death insurance case in the U.S. Court of Appeals - Prather v. Sun Life and Health Insurance Company, 2016 WL 7232144 (7th Cir. December 13, 2016) - /Cases/Prather-v-Sun-Life.pdf.   The case was brought on behalf of Lee Ann Prather, the widow of Jeremy Prather, who died at age 31 of a pulmonary embolism due to a deep vein thrombosis after undergoing surgery to repair his Achilles tendon which he ruptured while playing basketball.   Mrs. Prather brought a claim for accidental death insurance under a group policy issued to Jeremy's employer for the benefit of its employees.  However, the claim was denied based on coverage that was limited to "bodily injuries ... that result directly from an accident and independently of all other causes." (emphasis added).  The insurer maintained that Jeremy Prather's death was due to "complications from surgical treatment" and the district court upheld that finding.  The court of appeals reversed and awarded benefits to Lee Ann Prather.  

DeBofsky, Sherman & Casciari, PC