Articles Posted in ERISA

Fort Worth lawyers who handle ERISA plans have learned that almost all companies that have their own employee insurance plans will claim they are ERISA plans. The real question though is – are they?

Knowing which employee plans are true ERISA plans and which are not is not always easy to discovery. There are two sections of 29 USC that are helpful in this regard.

Sec. 1022. Summary plan description

De Sota insurance lawyers who handle ERISA claims need to read this opinion issued by the United States 5th Circuit Court of Appeals. It is styled, Robert George v. Reliance Standard Life Insurance Company.

Reliance denied George’s claim for benefits for two reasons, one of which will be discussed here.

George served as a helicopter pilot in the United States Army. In 1985 George was injured in a helicopter crash, and doctors were forced to amputate one of his legs at the knee. George retired from military service in 1987. After retiring, George began flying helicopters for PHI. PHI purchased a long-term disability insurance policy for George from Reliance (“RSL”). George flew for PHI for more than twenty years. But in 2008 he began experiencing severe pain at the site of his amputation, which prevented him from safely wearing his prosthetic limb. As a result, he was no longer able to operate the foot controls of a helicopter, and he was forced to retire from flying. At that time, he was earning $75,495 per year. George filed a claim for long-term disability benefits with RSL.

Fort Worth insurance attorneys handling ERISA claims need to read this case from the US 5th Circuit Court of Appeals. It is styled, Killen v. Reliance Standard Life Insurance Company.

Killen worked for Covenant from 2002 until March 2009, when she claimed that neck, shoulder and upper back pain made it too difficult for her to continue. Reliance Standard administered Covenant’s long-term disability plan which is governed by ERISA.

Killen collected benefits from June 2009 to June 2011. During this time, Killen separately qualified for Social Security disability benefits. To continue receiving benefits under the Plan after two years, a claimant must be “totally disabled” such that she is incapable of performing the material duties of any occupation for which she is qualified by way of education, training, or experience. Under the contract, an insured is totally disabled if “due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.”

Attorneys who do not handle ERISA claims often times make the mistake that there is not much difference between an ERISA insurance claim and a regular insurance claim. This is a mistake. The United States Court of Appeals for the Fifth Circuit issued an opinion on April 18, 2014, that discusses how courts looks at ERISA claims. The case is styled Cynthia Spenrath v. The Guardian Life Insurance Company of America. Here is some of the relevant information related to the case. However, for anybody dealing with an ERISA case, it is necessary to read the entire case and other cases dealing with ERISA law and issues.

Spenrath worked at Protect Controls, Inc. as an order entry manager. In 2005, Spenrath started having seizure-like episodes in which she would be non-responsive for about five minutes. She asserted that the episodes were accompanied by swishing in her ears, limb weakness, and an inability to move or speak. Spenrath’s primary care physician, Dr. Michael DiTeresa, referred her to two neurologists, Dr. Balbir Singh and Dr. J. William Lindsey. Neither neurologist made a definitive diagnosis, but they mentioned the possibility of multiple sclerosis based on abnormal MRI results and recommended additional testing. Spenrath did not undergo additional testing. Though she continued to take anticonvulsant medication, Spenrath did not visit the neurologists after 2005. In 2008, Spenrath experienced difficulty doing her job, with a diminished ability to focus and type information into the computer. When she failed to complete several assignments, she was given a negative performance review and a salary reduction. Shortly after the negative review, she ceased working on February 22, 2008. On May 7, Spenrath submitted a claim for long-term disability benefits under the company’s ERISA Plan, and claimed commencement of disability as of February 22, 2008.

The Plan’s administrator, Guardian Life Insurance Company (“Guardian”) began a review of the long-term disability claim. Under the Plan, Guardian has “discretionary authority to determine eligibility for benefits and to construe the terms of the [Plan] with respect to claims.” In order to receive long-term disability payments, the plan sets forth several requirements:

Insurance law attorneys who deal with ERISA plans, do so with a lot of caution. ERISA stands for Employee Retirement Income Security Act.

ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by:

Requiring the disclosure of financial and other information concerning the plan to beneficiaries;