Articles Posted in Disability Policies

Here is a case wherein one of the issues was whether or not an employee was eligible for Long Term Disability (LTD) based on the definition in the policy of “full time” employee.

This is a 2022, case is from the 5th Circuit Court of Appeals. It is an appeal from the Northern District of Texas.  The opinion in the case is styled, James W. Newsom v. Reliance Standard Life Insurance Company.

Newsome had a policy that, among other things, provided short term disability (STD) benefits and LTD benefits.  The plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA).

Lawyers who handle long-term disability (LTD) claims that are governed by the Employee Retirement Income Security Act of 1974 (ERISA), will want to read this opinion.  The opinion is titled, Enrique Talamantes v. Metropolitan Life Insurance Company.  It is a 2021, opinion from the United States Fifth Circuit.  It is a ruling that is favorable to the insured, which is unusual in cases governed by ERISA.

Plaintiff, was an engineer for him employer, BD.  BD provided its employees LTD coverage through plans governed by ERISA.  During the relevant time period, BD used two insurers, Standard Insurance Co. (“Standard”) for the 2016 calendar year and MetLife Insurance Co. (“MetLife”) for the 2017 calendar year, to fund LTD payments under the Plan.

On November 9, 2016, Plaintiff became disabled due to trigeminal neuralgia and underwent microvascular decompression surgery.  In light of this disability, Plaintiff was approved for and paid short-term disability(“STD”) benefits for 34 days under the Plan from November 18, 2016 through December 22, 2016.  The Plan’s STD benefits were paid by BD and administered by Sedgwick Claims Management Services (“Sedgwick”) and did not involve Standard or MetLife.  On December 23, 2016, Plaintiff returned to full-time active work.  Standard’s policy terminated on December 31, 2016, and MetLife’s policy became effective on January 1, 2017. On January 12, 2017, Plaintiff stopped working and again became disabled because  of a relapse in his trigeminal neuralgia symptoms.

Long Term Disability (LTD) claims are not uncommon in the insurance world.  Some of these claims are easy to see and understand, such as an amputation.  Other LTD claims are less easy to see and understand, such as chronic conditions and conditions that do not show up easily on tests and can be very subjective.  It is the other type of LTD claims that end up being denied by insurance companies.

While many denied claims can be contested by hiring an insurance lawyer, many are complicated legal battles.  What makes too many of these LTD claims even harder to contest if denied, is when the plan is through a person’s employer and governed by the Employee Retirement Income Security Act (ERISA).

A 2021 opinion from the Southern District of Texas, Houston Division, deals with an LTD claim that is governed by ERISA.  The opinion is styled, Mark Calkin v. United States Life Insurance Company In The City Of New York.

Here is a somewhat lengthy opinion in a case involving the Employee Retirement Income Security Act (ERISA) and a disability claim.  The opinion is from the Western District of Texas, Austin Division, and is styled, Jason Thomas Young v. Reliance Standard Life Insurance Company and Matrix Absence Management, Inc.

Plaintiff, Young, was insured by way of an ERISA disability plan through his employer when he was injured in an automobile accident.  He applied for and received disability benefits.  At a later date is recovered a substantial settlement from the insurance company of the person with whom he had the accident.  The disability plan administrator then attempted to offset the monies Young received from payments Young was receiving for disability pay.

Young filed suit and the plan administrator rescinded their earlier decision to offset payments.  After agreeing to make regular payments for disability without taking into account any offsets, the plan administrator filed a Rule 12(b)(1) and Rule 12(b)(6) motions to dismiss Young’s claim based on the assertion that the matter was now moot and that Young has no standing to continue the lawsuit.

Here is yet another ERISA claim being denied by the Federal Courts.  This case is from the United States Fifth Circuit Court of Appeals and is styled, Deo G. Shanker v. United Omaha Life Insurance Company.

The District Court granted United’s summary judgment motion and this appeal followed.

Shanker was President of a company called Intracare and United was the insurer under an ERISA plan which provided for long-term-disability (LTD) benefits.  To qualify for LTD benefits, Shanker had to become “Disabled due to an Injury or Sickness, while insured under the Policy.”  Disabled is defined to mean: “Because of Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred in which you are prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis ….”  Material Duties is defined as “the essential tasks, functions, and operations relating to an occupation that cannot reasonably omitted or modified” and includes “the ability to work for an employer on a full-time bases.”  Regular Occupation is defined as “the occupation You are routinely performing when Your Disability begins.”  The definition in the policy also notes:

Insurance attorney who handle denied claims and in particular insurance attorneys who are willing to take on an insurance claim governed by ERISA claim which has been denied, needs to read this opinion from the Eastern District of Texas, Sherman Division.  The case is styled, Gina Pike v. Hartford Life And Accident Insurance Company.

Pike had received long term disability (LTD) benefits from Hartford from April 24, 2008 through December 14, 2016, the period of time when Hartford determined Pike met the definition of disability in the LTD policy.  Later, after determining Pike was unable to prove she continued to be disabled under the policy, the benefits ceased on December 15, 2016.

This case resulted in a 51 page opinion which is not going to be discussed at any length here.  What is relevant is that it is rare for beneficiaries of these employer sponsored benefit plans and as a result needs to be carefully read to determine what the Court saw that separated this case from other ERISA cases.