75 results for 'cat:"ERISA" AND cat:"Insurance"'.
J. Nye denies in part an employer's and insurer's motion to dismiss a father and employee's allegations of violation of The Mental Health Parity and Addiction Equality Act (MHPAEA) after his son, a beneficiary of the plan, was denied benefits for inpatient and outpatient mental health treatment following the son's suicide attempt. The father "has presented a plausible cause of action that Defendants violated the MHPAEA by requiring more of persons seeking mental health/substance abuse treatment than other medical treatments."
Court: USDC Idaho, Judge: Nye, Filed On: May 2, 2024, Case #: 1:23cv221, NOS: Insurance - Contract, Categories: erisa, insurance
J. Alston grants the physical therapist motion for summary judgment in this ERISA action. The physical therapist stopped working due to symptoms of arthralgia, back pain, neck pain from cervical herniated discs, fibromyalgia, chronic fatigue, Epstein Barre virus, IBS, and migraines. After several years of long-term disability, primarily for cognitive issues, the insurance company denied her 2022 request on the grounds that she had published books and began a blog during her time away from work. The therapist's doctor continued to vouch for her, saying she would be unable to do her job. The insurer wrongfully ignored that evidence and relied solely on outlier opinions to determine its denial.
Court: USDC Eastern District of Virginia, Judge: Alston, Filed On: April 10, 2024, Case #: 1:23cv1, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, Labor
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. Aslan grants, in part, a video game developer and its insurance agency’s motion to dismiss and motion to strike this healthcare insurance coverage dispute brought by a former media artist. The artist alleges the developer and its insurer violated ERISA by denying her COBRA benefits. Her interference and retaliation, COBRA violation and breach of fiduciary duty claims fail to state a claim for relief, and her motion to strike the jury is denied as moot. The artist shall file a stipulation of dismissal for the claims that still remain in action for the third-party benefit administrator after they did not join in on this motion to dismiss.
Court: USDC Maryland, Judge: Aslan, Filed On: March 29, 2024, Case #: 1:23cv1270, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, Fiduciary Duty
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J. Vera grants an insurance company's motion to dismiss a cardiovascular surgeon's allegations that the insurer did not fully pay for services provided. ERISA supersedes state laws and "presents aggrieved plaintiffs—including medical providers who have been assigned the right to pursue their patient’s health care benefits—with a remedy." The surgeon is granted leave to amend to be permitted to plead ERISA claims.
Court: USDC Central District of California, Judge: Vera, Filed On: March 29, 2024, Case #: 2:23cv10071, NOS: Other Statutory Actions - Other Suits, Categories: erisa, insurance
J. Nelson denies summary judgment to the metals company against the hand grind/production grinder's complaint alleging that the metals company improperly denied the grinder's claim for short-term disability benefits under the sponsored plan to treat his liver abscess. There is a genuine issue of material fact about whether the metal company's denial of the grinder's benefits after Dec. 4, 2020, when the plan was set to end even though the grinder made claims and appeals before then, was unreasonable when considering the entire administrative record.
Court: USDC Oregon, Judge: Nelson, Filed On: March 26, 2024, Case #: 3:22cv681, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance
J. Marbley grants the insurer's motion for judgment on the administrative record, ruling that while the employee's health has suffered as a result of "long Covid-19," evidence in the record indicates she was able to job on a semi-daily basis and was cleared to return to work by a physician, which is sufficient to support the denial of long-term disability benefits.
Court: USDC Southern District of Ohio, Judge: Marbley, Filed On: March 25, 2024, Case #: 2:22cv3118, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, Evidence, insurance
J. Moon grants the employee's motion for summary judgment. The employee initially stopped working after an extreme case of hyperthyroidism before his doctor said he was fit to go back to work. The hyperthyroidism caused cognitive decline to the point that he cannot perform simple tasks, remember what he is saying midsentence, or count. He successfully argued that his insurance company wrongly denied him long-term disability benefits for his cognitive issues. The insurance company never gave the independent reviewers hired to determine his disability status crucial affidavits submitted by him, his wife, his mother-in-law, and friends attesting to instances where his impaired cognition manifested.
Court: USDC Western District of Virginia, Judge: Moon, Filed On: March 19, 2024, Case #: 6:2cv6, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, Labor
J. Willett withdraws the previous opinion and substitutes this one, finding the district court improperly awarded the debilitated former NFL running back top tier NFL plan disability benefits. Although the plan’s review board may have denied the retired player a full review, and he is most likely entitled to the highest level of disability pay, he is not entitled to reclassification. He has not shown changed circumstances between a previous application and his claim for reclassification, which was denied and which he did not appeal. Reversed.
Court: 5th Circuit, Judge: Willett , Filed On: March 15, 2024, Case #: 22-10710, Categories: erisa, insurance
J. Melgren grants a former employee's motion for summary judgment concerning an insurance company's denial of disability benefits under ERISA. The former employee, who developed a serious back pain condition at work, sufficiently showed in court that he was disabled while under the plan before he lost his job.
Court: USDC Kansas, Judge: Melgren, Filed On: February 14, 2024, Case #: 2:23cv2054, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: Employment, erisa, insurance
J. Pechman awards the insured $49,500 in attorney fees for their complaint that the insurance company wrongfully denied the minor rehabilitation services without a full and fair review. The insurance company's bad faith and culpability warrants attorney fees, because while the insurance company argues that it only needs to show that the insurance company had a reasonable basis to deny coverage to qualify as good faith, this argument misreads the court's order on cross-motions and relies on two inapplicable 9th Circuit cases.
Court: USDC Western District of Washington, Judge: Pechman, Filed On: February 9, 2024, Case #: 2:22cv1517, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, Attorney Fees
J. Shubb finds for a life insurance company on a widow’s ERISA claims arising from the denial of accidental death benefits when her husband, who was employed by a grocery store chain and was learning to fly allegedly store-owned aircraft, died following a fatal crash. The company's policy included an aircraft exclusion that applied to the decedent, as he was considered part of the crew, rather than a passenger, at the time of the accident.
Court: USDC Eastern District of California, Judge: Shubb, Filed On: January 26, 2024, Case #: 2:23cv919, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: Employment, erisa, insurance
J. Conley grants summary judgment to the insurance company in the beneficiary's lawsuit claiming it wrongfully denied her claim for long-term disability benefits after she stopped working in June 2022 due to cognitive issues, eye problems, hand numbness, shoulder pain, chronic kidney disease and other complications from diabetes. Through the denial of her initial claim and two subsequent appeals, the insurance company was not arbitrary and capricious in making its decisions based on the beneficiary's medical records and ability to perform her job in light of the combined effect of all her ailments, many of which the evidence shows were stable or improving.
Court: USDC Western District of Wisconsin, Judge: Conley, Filed On: January 24, 2024, Case #: 3:22cv494, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance
J. Peterson grants summary judgment to the insurance company in a lawsuit from a beneficiary claiming she was wrongfully denied long-term disability benefits after she stopped working in January 2021 due to eye pain and spasms. Through the beneficiary's initial claim and two subsequent appeals, the insurance company comprehensively reviewed all the evidence and medical opinions related to the beneficiary's pain and the limitations her conditions placed on her ability to do her job, and it cannot be found to have been arbitrary and capricious in its decisions.
Court: USDC Western District of Wisconsin, Judge: Peterson, Filed On: January 22, 2024, Case #: 3:22cv617, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance
J. Brady rules in part for the insurer because the policyholder failed to convert her employment life insurance policy into a personal policy prior to her death. However, the claim should not be dismissed, as while the insurer did not have a duty to inform her of her policy rights, she was experiencing mental decline.
Court: USDC Northern District of Indiana, Judge: Brady, Filed On: January 11, 2024, Case #: 3:23cv290, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: Civil Procedure, erisa, insurance
J. Mendoza finds that the district court improperly dismissed an ERISA action brought by a surgery center which sought reimbursement from Anthem Blue Cross, an insurer and claims administrator, for the costs of medical services provided to patients. Under longstanding precedent, a healthcare provider has derivative authority to enforce ERISA’s protections if it has received a valid assignment of rights. The patients effectuated a valid assignment under the surgery center's “Assignment of Benefits.” Reversed.
Court: 9th Circuit, Judge: Mendoza, Filed On: January 10, 2024, Case #: 22-55717, Categories: erisa, Health Care, insurance
J. Pechman grants the family judgment on their ERISA claims accusing the insurance company and others of wrongfully denying coverage for the minor, who was under the father's plan, for his stays at mental healthcare facilities in 2019 and 2020. The insurance company abused its discretion in policy determination because it denied full coverage without providing a reasonable explanation for why the minor did not need further treatment at one of the mental healthcare facilities. The insurance company must complete its review and determination of what is owed to the family.
Court: USDC Western District of Washington, Judge: Pechman, Filed On: December 18, 2023, Case #: 2:22cv1517, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance
J. Zilly denies the employee's motion to amend the judgment for her complaint that the insurance company wrongfully denied her claim for long-term disability benefits under an employee benefit plan. The employee shows a taxable 2015 income of $104,500 but she does not show that this income is solely from her employment, or that it was her base salary without added funds such as bonuses and overtime pay. The insurance company is to calculate the employee's claim for LTD benefits according to the policy, and then it is to pay pre-judgment interest at a 5.46% rate per annum on unpaid LTD benefits from Oct. 6, 2020 until Oct. 6, 2023, the date of judgment.
Court: USDC Western District of Washington, Judge: Zilly, Filed On: December 18, 2023, Case #: 2:21cv1424, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: Employment, erisa, insurance
J. Blumenfeld Jr. grants the insured $312,300 in attorney fees and $3,800 in costs for her complaint that the insurance company made an error in overpaying her $56,400 in long-term disability benefits over nine years and then demanded she pay the company back when it discovered the mistake. The insured seeks $571,100 in attorney fees for nearly 850 time entries for four years of work, but that amount is reduced because a number of items are excessive, redundant and unnecessarily billed, and there is sometimes "a mismatch between counsel’s experience offered to justify high hourly rates and the amount."
Court: USDC Central District of California, Judge: Blumenfeld Jr., Filed On: December 13, 2023, Case #: 8:20cv821, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, insurance, Attorney Fees
J. Bryan denies the insurance company's motion to decertify the class in the insureds' class action asserting that the insurance company must cover treatment of gender dysphoria and gender reassignment surgery for a minor. Not only are the class members not seeking individualized damages, which would preclude class certification, but the insurance company's discriminatory conduct described in prior orders is uniform among all plans and all class members.
Court: USDC Western District of Washington, Judge: Bryan, Filed On: December 11, 2023, Case #: 3:20cv6145, NOS: Insurance - Contract, Categories: erisa, insurance, Class Action
J. Reidinger grants a health benefits management firm’s motion to dismiss a claim brought by a mother when her child, a beneficiary, was treated at a residential mental health facility. The firm denied the claim citing an exclusion in the mother’s health care plan. The mother exhausted the appeals process with the firm, then filed the current action to recover the cost of the claim through ERISA. However, the firm is no longer the claims administrator for the mother’s plan and so cannot provide relief.
Court: USDC Western District of North Carolina, Judge: Reidinger, Filed On: December 6, 2023, Case #: 1:21cv265, NOS: Employee Retirement Income Security Act (ERISA) - Labor, Categories: erisa, Health Care, insurance