In Rose v. PSA Airlines, Inc., the Fourth Circuit Court of Appeals ruled that a self-funded group health plan may be sued for monetary damages for failure to approve a medical procedure for a plan...
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Benefit Claims
Claims Denial Overturned for Failure to Follow Claims Procedures
The U.S. Court of Appeals for the Tenth Circuit, in David P. v. United Healthcare Ins. Co., has reversed a group health plan’s benefits claim denial because the plan’s claims administrator failed to...
Claims Appeals Procedures Must be in Formal Plan Documents
Claims Appeals Procedures Must be in Formal Plan Documents - Marcia Wagner, 401(k) Advisor, Volume 30, No. 7, July/August 2023
Plan Administrators May Not Adopt Rationales for Benefit Denials Not Raised During the Claims Review Process
The Ninth Circuit Court of Appeals, in Collier v. Lincoln Life Assurance Co. of Boston, has held that when a district court engages in a de novo review of an ERISA plan administrator’s denial of...
Delay in Final Claims Appeal Determination Excuses Claimant from ERISA’s Exhaustion of Administrative Remedies Requirement
The Second Circuit Court of Appeals, in McQuillin v. Hartford Life & Accident Ins. Co., has ruled that a claimant exhausted his plan’s administrative remedies and was, therefore, entitled to sue...
Plan’s Lawsuit Deadline Not Enforceable Unless Communicated in Final Claims Denial
In two recent cases, a judge in the United States District Court for the District of Utah has ruled that, if an ERISA welfare benefit plan sets a time limit on when a claimant may file a civil...
Ninth Circuit Finds Welfare Plan Did Not Abuse Its Discretion In Denying Benefits
The Ninth Circuit Court of Appeals, in Alves v. Hewlett-Packard Comprehensive Benefits Plan, has found that a welfare benefit plan’s claims administrator did not abuse its discretion in denying a...
Court Says No Specific Wording Required in Plan Document to Give Plan Discretionary Claims Authority
The Second Circuit Court of Appeals, in Tyll vs. Black and Decker Life Insurance Program, has ruled that a plan document is not required to use any specific language in order to give the plan...
Court Confirms Participant Must Exhaust Administrative Remedies Before Filing a Suit
The U.S. District Court for the Southern District of New York, in Benson vs. Tiffany and Company SPD, has ruled that a participant in an ERISA-governed group health plan may not proceed with her...