ERISA

ERISA – Total Disability

August 20, 2016 | Mark S. Humphreys

ERISA lawyers know how tough these ERISA claims are. This is illustrated in a case from the Texas Southern District styled, Sarmiento v. Metropolitan Life Insurance Co.

Tammy Sarmiento sued for wrongful denial of benefits under ERISA, 29 U.S.C. 1332. The plan is through her employer, American Airlines. Her claim for long-term benefits was denied by the plan administrator. The Plan automatically ends long-term disability benefits (a) when the employee is no longer totally disabled as defined by the Plan and (b) after twenty-four months if the disability is for a mental-health disorder.

Tammy worked as a staff assistant. In August of 2011, she stopped working because she was having short-term memory loss. She was diagnosed with encephalopathy, major depression disorder, and frontal lobe syndrome. Under the Plan, encephalopathy is a physical condition. She applied for and received short-term and long-term benefits.

ERISA Versus State Law

June 14, 2016 | Mark S. Humphreys

ERISA lawyers in the Dallas / Fort Worth can tell you how powerful ERISA is and that the rules governing ERISA plans pre-empt State rules governing insurance. This is argued in a Northern District, Dallas Division case styled, Curtis v. Metropolitan Life Insurance Company.

This case concerns a three-party contractual relationship between Curtis (Plaintiff), his employer (EFH), and MetLife. The contractual relationship is governed by ERISA.

Three documents encapsulate the terms of this relationship: the EFH Master Plan Document, the EFH Summary Plan Description (SPD), and the MetLife Certificate of Insurance (COI).

ERISA Disability Claims

May 29, 2016 | Mark S. Humphreys

This 5th Circuit Court of Appeals opinion is a must read for ERISA attorneys. The case is styled, Burell v. Prudential Insurance. The facts will be given here. The case needs to be read to understand how the Court affirmed the findings of the lower Court in denying benefits to Burell.

In 1985, Burell began working as an entry-level technician for Methodist Healthcare Systems (“MHS”). After 26 years, he ended his career as Director of Biomedical Services for all San Antonio MHS facilities. As an employee of MHS, Burell participated in the company’s insurance plan (“the Plan”), which is provided through HCA Management Services, L.P. Prudential acts as both administrator and insurer of the Plan. In order to qualify for long-term disability benefits, a claimant must meet the following definition of “disabled”: the claimant must (1) be “unable to perform the material and substantial duties of [his or her] regular occupation due to [his or her] sickness or injury “; (2) be “under the regular care of a doctor “; and (3) suffer “a 20% or more loss in [his or her] monthly earnings due to that sickness or injury.”

Burell was diagnosed with multiple sclerosis (“MS”) in 2008. Citing worsening symptoms of MS, in September 2011, Burell went on medical leave and filed for long-term disability benefits with Prudential, claiming that he qualified for benefits under the Plan due to MS, headaches, depression, and anxiety. In January 2012, he stopped working altogether, ending his employment with MHS. In support of his claim, Burell submitted medical records from his treating physicians and a psychiatrist. Prudential hired Heidi Garcia, a registered nurse, and Dr. Alan Neuren, who is board certified in neurology, to review Burell’s claim. Dr. Neuren found that Burell’s diagnosis of MS was unsupported by his medical records. He also found it unlikely that Burell suffered any cognitive impairments, opining that job stress is “likely the source of his complaints as opposed to a neurological disorder.” Garcia focused her review on Burell’s claim of depression and anxiety, ultimately finding that any cognitive symptoms he was experiencing were not sufficient to prevent him from working. Based on their reports and the medical records submitted, Prudential denied Burell’s claim for long-term disability benefits.

ERISA And Time Limitations For Appeal

May 26, 2016 | Mark S. Humphreys

ERISA lawyers can tell you that the rules with ERISA claims are pretty tough. This is illustrated by a Dallas Division opinion issued in March 2016. The style of the case is, Sharon Smith v. The Boeing Company.

Sharon sued Boeing seeking spousal pension benefits from her deceased husband’s retirement plan. On January 1, 2008, Henry Smith designated his former spouse, Trinette Smith as his primary beneficiary. Henry and Trinette later divorced, and Henry married Sharon in 2011. Henry attempted in a letter dated May 14, 2012, to change the primary beneficiary to Sharon. The request was denied because Henry had already begun receiving his pension benefit.

After Henry’s death in July 2013, Sharon requested that Boeing recognize her as the beneficiary. In a letter dated October 14, 2013, Boeing informed Sharon her request was being denied because she was not the listed spouse at the time of Henry’s retirement. Sharon was also informed of rights under ERISA and under Section 502(a) she had no later than 180 days to appeal the decision which she did.

ERISA And Life Insurance

May 19, 2016 | Mark S. Humphreys

ERISA lawyers should read the opinion 2016, opinion from the Houston Division, Southern District of Texas. The case is styled, Margaret Myklebust v. McDermott, Inc., et al.

Plaintiff sued MetLife seeking a declaration that she is entitled to recover life insurance benefits attributable to the decedent, John Drayton, as his surviving spouse.

A Motion For Summary Judgment was filed and the Court ruled in favor of Plaintiff. In rendering its decision the court discussed the facts of the case.

ERISA Or Not

April 28, 2016 | Mark S. Humphreys

ERISA lawyers will tell you that sometimes determining whether or not a plan is an ERISA plan or not can be confusing. The U.S. Southern District, Houston Division, issued an opinion that needs to be read on this issue. The style of the case is, Williams v. United Healthcare of Texas, Inc.

Williams had medical coverage under her employer plan for Retirees and Other Eligible Individuals (“the Plan”) with United Healthcare of Texas, Inc. and administered through UMR, Inc. Williams suffered from serious acid reflux pain and was diagnosed with esophageal diverticulum and hiatal hernia. Williams’s doctors determined that her condition would require surgery. On September 8, 2014, Williams entered the hospital and was released the following day. Five days later, Williams suffered complications from surgery and returned to the hospital. Williams remained under doctor’s care from September 13, 2014, to October 13, 2014. On September 17, 2014, and October 3, 2014, Williams received confirmation from Defendants that additional surgery was medically necessary. Williams was later transferred to the hospital. On November 3, 2014, Williams received correspondence from Defendants authorizing the additional medical procedures in Houston. Williams alleges that Defendants later denied her coverage under the Plan despite authorizing the treatment on multiple occasions.

Williams filed a lawsuit. Defendants removed the case to Federal Court based on Williams claims being pre-empted by ERISA.

ERISA Wants All The Money

March 6, 2016 | Mark S. Humphreys

Attorneys handling ERISA claims can tell you that the ERISA plan wants back all the money they spend on their beneficiary’s claim. The United States Supreme Court rendered a notable opinion in January 2016. The case is styled, Board of Trustees of the National Elevator Industry Health Benefit Plan v. Robert Montanile. Here is what the Courthouse News Service has to say.

The Supreme Court threw out a decision Wednesday that would have a car-accident victim who settled with the other driver reimburse medical coverage.

The Board of Trustees of the National Elevator Industry Health Benefit Plan paid more than $121,000 after Robert Montanile, a covered employee, suffered injuries in a Dec. 1, 2008, car accident.

ERISA Briefly

February 7, 2016 | Mark S. Humphreys

ERISA lawyers are in a position to be the bearers of bad news as it relates to persons having ERISA claims. Here are some paragraphs from a recent article on ERISA submitted to the State Bar of Texas.

ERISA, Employee Retirement Income Security Act of 1974. This is a federal program originally designed to be of benefit to employees who work in the private sector in this country. Although the primary focus is the protection of pension benefits, the Act’s application is broad, covering health, disability, and life insurance benefits offered to private-sector employees. Health, disability and life insurance benefits are collectively referred to as welfare benefits within ERISA, and the Act provides that those who administer welfare benefit plans are subject to some of the same fiduciary responsibilities as administrators of pension plans. The Act included the creation of pension insurance administered by the Pension Benefit Guaranty Corporation, providing employees a government guaranty that upon retirement they would receive at least some, if not all, of their vested pension benefits if their employer could not meet its pension obligations.

Congress explained its purpose in enacting ERISA within the first section of the Act:

ERISA Accidental Death Benefits

January 16, 2016 | Mark S. Humphreys

Dallas area attorneys handling life insurance benefits under an ERISA plan need to read this 5th Circuit opinion. It is styled, Judy Hagen v. Aetna Insurance Company; Hewlett Packard Company.

David Hagen was an employee of Hewlett and had life insurance coverage under a company benefits plan administered by Aetna.

The terms of the Policy state that to receive payment under the accidental death benefit provisions, Aetna must receive proof that, inter alia, death “was a direct result of a bodily injury suffered in an accident.” The Policy states that an “accident” is “a sudden and external trauma that is; unexpected; and unforeseen; and is an identifiable occurrence or event producing, at the time, objective symptoms of an external bodily injury.” To qualify as a covered “accident,” an occurrence or event “must not be due to, or contributed by, an illness or disease of any kind including a reaction to a condition that manifests within the human body or a reaction to a drug or medication regardless of the reason the insured has consumed the drug or medication.” The Policy defines “injury” as “an accidental bodily injury that is the sole and direct result of . . . an unexpected or reasonably unforeseen occurrence or event . . . or the reasonable unforeseeable consequences of a voluntary act by the person.” The Policy specifies that “an injury is not the direct result of illness,” and defines illness as “[a] pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings peculiar to it and that sets the condition apart as an abnormal entity differing from other normal or pathological body states.”

ERISA And Efforts To Avoid It

January 14, 2016 | Mark S. Humphreys

Lawyers handling ERISA claims can tell horrible stories of the injustice that has occurred in the handling of ERISA claims. The State Bar of Texas, Insurance Section published an article that discussed some of the issues harming people.

Although the Act’s purpose was to promote the creation of employee benefit plans and protect those benefits for employees, since ERISA’s enactment most employees with pension or welfare benefit claims do whatever they can to escape the “protections” of the Act, while insurance carriers and employers that fund and administer the benefit plans push to have the claims governed by ERISA. Case law portraying an employee’s struggle to have his or her pension or welfare benefit claim governed by ERISA is almost non-existent. Instead, ERISA benefit case law over the last forty years reveals a common theme: the employee’s Sisyphean struggle to avoid ERISA.

The mountain of cases finding preemption is tall and imposing. The employee stands in the valley with her claim, her rock, using every ounce of physical energy and creative power to push her rock up and over the mountain, to free herself from the Act designed for her benefit. The fiduciary stands calmly upon the side of the mountain, seeking to return the rock to the valley where the protections of the Act lie, pressing the already heavy rock against the employee’s skin, muscle, and bone, forcing it back downhill. Naturally, given the slope of the mountain and the application of pressure by the fiduciary, the rock almost always returns to the valley. The employee watches hopelessly as her heavy burden crashes back down the hill, seeing with despair that all of her toil was for nothing. She is confined to the valley. Many claimants, especially those who are already impaired when they began their quixotic ascent, remain beaten.