Dallas Fort Worth Insurance Lawyer Blog

Long-Term Disability Benefits & ERISA

August 23, 2021 | Mark S. Humphreys

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.

Accidental Death Insurance Policy – ERISA

August 21, 2021 | Mark S. Humphreys

Life insurance denials are much more common than people realize. Most people would be of the opinion that once a person had paid for life insurance and then a death occurs, that the policy would pay. That is not the case.

Here is an opinion from the Southern District of Texas, Houston Division. It is styled, Sydney Joe Gray v. Minnesota Life Insurance Company. This case involves an accidental death policy that is governed by the Employee Retirement Income Security Act of 1974 (ERISA).

The lawsuit is brought under 29 U.S.C., Section 1132(a)(1)(B). The deceased, Michael Gray had an accidental death policy he obtained through his employment. Sydney Gray is the beneficiary of the policy.

Claims Denial – Suing The Adjuster

August 16, 2021 | Mark S. Humphreys

Insurance lawyers time and time again have a difficult time properly suing insurance adjusters when their case is in Federal Court. This is illustrated in a June 16, 2021, opinion from the Northern District of Texas, Dallas Division. The opinion is styled, Thomas Paredes and Kerry Paredes v. The Cincinnati Insurance Company and John Schuster.

The Paredes had their property insured through Cincinnati. They incurred a hail storm loss properly reported it. Cincinnati assigned adjuster, Schuster to the claim. The Paredes were dissatisfied with the way the claim was handled and filed the present suit. The lawsuit was timely removed to Federal Court on the basis that Schuster (the Adjuster) was improperly joined and that without the Adjuster, diversity jurisdiction existed. The Paredes filed a motion to remand which is the subject of this opinion.

Cincinnati says the Adjuster was improperly joined in the lawsuit because the Paredes have not stated a cause of action against him.

Life Insurance Attorney’s And Beneficiary Dispute

August 14, 2021 | Mark S. Humphreys

Life Insurance lawyers often see disputes over who is entitled to life insurance proceeds.

A 2021, opinion from the Southern District of Texas, Houston Division, is a dispute over who is entitled to life insurance proceeds. Also, the life insurance policy at issue in this case is governed by the Employee Retirement Income Security Act of 1974, (ERISA). The opinion is styled, Christine and Denise Morgan v. Prudential Life Insurance – Prudential Life Insurance v. Linda Arriazola and Elvia Barrera.

This case was decided on competing motions for summary judgment.

A Unique Way To Stay Out Of Federal Court

August 9, 2021 | Mark S. Humphreys

Here is a unique way to stay out of Federal Court. It is applicable to suing a Lloyd’s of London insuring entity. The case is a 2021, opinion from the Northern District of Texas, Fort Worth Division. It is styled, Certain Underwriters At Lloyd’s, London Subscribing Severally To Policy No. B0595NOHW46387019 v. Block Multifamily Group, LLC D/B/A Block Multifamily Power Group.

Following an insurance dispute with Lloyd’s, Block filed a lawsuit in a State Court. Lloyd’s removed the case to Federal Court , and then Block filed a motion to remand, which is the subject of this opinion.

Defendant removed the case to this Court on the basis of diversity jurisdiction, alleging that Plaintiffs are foreign citizens of England and that Defendant is a citizen of Missouri. Defendant further alleged that the amount in controversy exceeds $75,000 because the value of the underlying dispute based on Plaintiffs’ own estimate is at least $177,023.21. Shortly thereafter, Plaintiffs filed their Motion to Remand on the ground that Defendant has improperly conflated Lloyd’s of London—a specific entity—with the Plaintiffs in this case—over 1,600 individual underwriters or “Names.” Relying on Corfield v. Dallas Glen Hills, L.P., 355 F.3d 853 (5th Cir. 2003), Plaintiffs explain the distinction as follows:

Suing The Business Entity Rather Than The Insurance Company

August 7, 2021 | Mark S. Humphreys

Here is an unusual situation from the Northern District of Texas, Dallas Division. The opinion is styled, Barry Green, Individually and as Attorney in Fact for Billie Green and Billie Green, Individually v. Allstate Texas Lloyds, Inc.

If the unusual aspect of this case is not pointed out in the beginning, some will miss it. The Plaintiffs sued Allstate Texas Lloyds, Inc., rather than the insurance company Allstate Texas Lloyds.

The Plaintiffs had homeowners insurance coverage and sued Allstate Inc. in State Court. Allstate Inc. then removed the case to Federal Court citing that the wrong entity had been sued and that Allstate Inc. was a Texas Company but Allstate Lloyds was not a Texas company and thus, the correct party, Allstate Lloyds created diversity jurisdiction, making removal proper.

Palo Pinto County And Hail Damage Claim

August 2, 2021 | Mark S. Humphreys

The Northern District of Texas, Fort Worth Division, decided a case in 2021 wherein the lawyer for insured did a good job of pleading his case. The strange thing about this case is that it was filed in 2021, well after the new section of the Insurance Code was in effect, that being section 542A. In section 542A, suing the adjuster has essentially been made something of the past, with rare exceptions. However, it is not the issue in this case but the case still serves as a good example on how to name the insurance adjuster in such a way as to keep the case in State Court rather than being removed to Federal Court.

The style of the case is, Paradise Villas HOA, Inc. v. Amguard Insurance Company and Todd Anthony Gilmore. Paradise is the insured, Amguard is the insurer, and Gilmore is the adjuster.

Paradise suffered alleged hail damage and properly reported the claim to Amguard. Gilmore, a Texas Citizen, was assigned to adjust the claim and according to Paradise, Gilmore greatly under estimated the value of the claim. A lawsuit was filed in State Court and Amguard caused the case to be removed to Federal Court alleging that Gilmore was improperly named in an effort to defeat diversity jurisdiction and asserting that the causes of action asserted against Gilmore could not stand. Paradise filed a motion to remand which is the cause of this opinion.

Hail Damage Claims

July 31, 2021 | Mark S. Humphreys

Here is an interesting case dealing with hail damage. This is a 2021, case from the San Antonio Court of Appeals. It is styled, Allstate Vehicle And Property Insurance Company v. Peter Reininger. The opinion is an appeal from a jury trial in favor of Reininger.

The opinion is lengthy and discusses several legal issues. However, the facts of the case are pointed out here because the facts are similar to situations many other homeowners face themselves.

Reininger’s home had previously been covered by a policy issued by Liberty Mutual and that policy covered cosmetic hail damage to his metal roof. When Reininger began looking for a new policy in 2015, he contacted Justin Losoya, an Allstate agent. Reininger told Losoya he wanted a policy that was “apples to apples” with his Liberty Mutual policy, and Losoya stated Allstate could provide that. Reininger also asked Losoya, “If I have any bad weather, hail or any type of hail and it damaged my roof, am I covered?” Losoya answered, “Yes, sir, Mr. Reininger, you are. You pay a 1 percent deductible.” Losoya did not mention any exclusions on coverage for the roof, and Reininger did not make any further inquiries about exclusions.

Claims Denial Attorneys – Read This

July 26, 2021 | Mark S. Humphreys

Here is a 2021, case from Southern District of Texas, McAllen Division, that discusses how courts are to review motions for summary judgment. The opinion is styled, Saul Cantu v. United Property And Casualty Insurance Company.

The dispute revolves around a homeowners claim where Cantu suffered alleged damage to his property and then made a claim against his insurance company, United Property. United Property subsequently denied the claim and eventually filed a motion for summary judgment.

Reading the opinion will set up the facts of this case, however, the focus here is the analysis by the court in this summary judgment opinion.

ERISA – Insurance Claims Denial

July 24, 2021 | Mark S. Humphreys

The Employee Retirement Income Security Act of 1974, (ERISA) applies to a majority of employer provided insurance plans. These plans include, life, disability, and health. What is important to understand about ERISA plans is that it is rare in the extreme that a court will over-turn a decision by an ERISA plan administrator. This is seen again in a 2021 opinion from the Western District of Texas, Austin Division, styled, Marc Worob, individually and as next friend of M.W. v. Blue Cross And Blue Shield Of Texas, A Division Of Health Care Service Corporation.

This case is decided in favor of the insurance company plan administrator on competing motions for summary judgment.

The Plan provides coverage for five categories of Eligible Expenses: (1) Inpatient Hospital Expenses; (2) Medical–Surgical Expenses; (3) Extended Care Expenses; (4) special provisions expenses; and (5) pharmacy expenses. The first category, Inpatient Hospital Expenses, includes “Medically Necessary services for Serious Mental Illness in a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, a Residential Treatment Center for Children and Adolescents, or a Residential Treatment Center in lieu of hospitalization.” The Plan defines a Residential Treatment Center as a: