8 results for 'cat:"ERISA" AND cat:"Insurance" AND cat:"Contract"'.
J. Aenlle-Rocha grants an insured's motion to overturn the insurer's denial of benefits for his son's treatment at a residential care facility. The treatment was denied as "not medically necessary" despite the insured's appeal with neuropsychological assessments, five letters of medical necessity from treatment providers, and thousands of pages of medical records and treatment notes. The insured "has satisfied his burden of proving medical necessity as to the treatment at issue with credible, persuasive evidence." The insurer denied the claim without sufficient explanation and "disregarded relevant medical evidence and did not afford [the insured] a full and fair review of his claims."
Court: USDC Central District of California, Judge: Aenlle-Rocha, Filed On: April 9, 2024, Case #: 2:23cv6413, NOS: Other Contract - Contract, Categories: erisa, insurance, contract
J. Auld denies a former Duke University Medical Center doctor’s second motion to compel discovery pursuant to ERISA to recoup long-term disability benefits under his insurance plan. The doctor requests discovery of information he believes the company has withheld. However, the company has repeatedly provided all information requested and, so, will not be tasked with providing more.
Court: USDC Middle District of North Carolina, Judge: Auld, Filed On: October 4, 2023, Case #: 1:22cv605, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, contract
J. Grimberg finds in favor of the insurance company in a lawsuit from a beneficiary over the denial of her claim for long-term disability benefits filed when she stopped working after being diagnosed with scleroderma. The company successfully argues that given the timing of when the beneficiary became insured under the policy, when she received treatment for worsening symptoms and when she was actually diagnosed, her scleroderma was technically a pre-existing condition because she was treated for it during the three-month "look-back period" prior to her policy becoming effective, even though she was not diagnosed until after this period ended. These facts make the company's denial reasonable and neither arbitrary nor capricious, and the company's motion for summary judgment is granted and the beneficiary's motion for judgment on the administrative record is denied.
Court: USDC Northern District of Georgia, Judge: Grimberg, Filed On: September 29, 2023, Case #: 1:21cv2900, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, contract
J. Schroeder agrees with the findings and conclusions of the magistrate judge and grants-in-part summary judgment to the beneficiary on the claim for wrongful denial of benefits under the Employment Retirement Income Security Act. The insurer's objections are overruled, and the beneficiary is entitled to accidental death benefits since recovery is not barred by any of the cited policy exclusions.
Court: USDC Eastern District of Texas , Judge: Schroeder, Filed On: September 25, 2023, Case #: 5:21cv143, NOS: Insurance - Contract, Categories: erisa, insurance, contract
J. Fleming grants the ERISA plan administrator's motion to dismiss, ruling the successor company to the original policyholder was not named on the plan and, therefore, was not an intended beneficiary of the plan and cannot seek damages for a one-month gap in coverage.
Court: USDC Northern District of Ohio, Judge: Fleming, Filed On: August 21, 2023, Case #: 4:22cv208, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, contract
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J. Russell grants a group of financial and insurance firms their motion to dismiss a second amended ERISA complaint brought by a consulting company. The company argues that its claims are not preempted because the firms misrepresented the life insurance and annuity funding products to fund the ERISA plan. However, because the determination would need to be made that the plan was never suitable for the consulting company and, therefore, require a review of the plan, the company’s claims are preempted.
Court: USDC Maryland, Judge: Russell, Filed On: August 8, 2023, Case #: 1:21cv2493, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, contract
J. Readler finds that the lower court properly dismissed the ERISA claims brought by the injured driver on behalf of other plan members and the plan itself because his speculative allegations about the insurance company's scheme to collect reimbursement payments that were not actually included in the plan lack the specificity necessary to establish standing. However, the fiduciary duty and prohibited transaction claims brought solely by the injured driver were improperly dismissed because they were both equitable claims under ERISA and the $25,000 can be adequately traced by the driver after he settled with and reimbursed the insurance company. Reversed in part.
Court: 6th Circuit, Judge: Readler, Filed On: August 1, 2023, Case #: 22-3167, Categories: erisa, insurance, contract
J. Coughenour finds in favor of the insurance company for the beneficiaries' claim that the company wrongfully denied their claim for the daughter's stay at a residential mental health treatment provider, as the insurance company claims that another residential treatment stay was not medically necessary under the parent's self-funded Employee Benefits Plan. The insurance company engaged in a meaningful dialogue with the parent when discussing the denial of benefits, and the daughter did not meet the plan's InterQual criteria because it requires that a provider perform weekly psychiatric evaluations, but the provider only performed one evaluation on the daughter during her year-long stay.
Court: USDC Western District of Washington, Judge: Coughenour, Filed On: June 12, 2023, Case #: 2:21cv1611, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, contract