Adam V. Russo | August 27, 2010

Employer’s Guide to Self-Insuring Health Benefits, Thompson Publishing Group

Employers and other plan administrators are due greater deference in their benefits plan decisions than some lower courts have allowed, the U.S. Supreme Court ruled after admonishing two lower courts for failing to follow the High Court’s prior decisions establishing ERISA law on plan administration.

The High Court also admonished the current administration as well as courts for attempting to introduce more complex, inefficient and costly requirements in plan decision-making, and for encouraging court interference in those plan decisions. (more…)

Category: 2nd, ERISA, MetLife v. Glenn, PPACA, Summary Plan Description, Supreme Court | No Comments »
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Adam V. Russo | July 9, 2010

Sandra Chronister was employed as a nurse at Baptist Health in Arkansas. In 1995, she was injured in a car accident, and thereafter sought disability benefits under Baptist Health’s long-term disability plan, which was insured and administered by Unum Life Insurance Co. of America. Unum initially granted her application for disability benefits. At Unum’s urging, Chronister also applied for, and received, social security disability benefits. After twenty-four months, however, Unum informed Chronister that it was terminating her benefits under the “self-reported symptoms” limitation of the plan. Chronister exhausted her administrative remedies and then brought suit. The Eastern District of Arkansas ultimately determined that substantial evidence did not support Unum’s decision to deny Chronister benefits based on the self-reported symptoms limitation. The district court remanded the matter to Unum with directions to reopen the administrative record and make a new determination. (more…)

Category: 8th, Conflict of Interest, MetLife v. Glenn, Standings | No Comments »
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Adam V. Russo | July 9, 2010

In light of the Supreme Court’s decision in Glenn, the Second Circuit has reassessed its standard of review governing cases that challenge an ERISA plan administrator’s decision to deny disability benefits in cases where the administrator has a conflict of interest because it has the discretionary authority to determine the validity of the employee’s claim and pays the benefits under the policy. In McCauley, the Second Circuit abandoned its prior standard of review, which allowed courts to review de novo the administrator’s decision when it is shown that a conflict of interest actually influenced that decision, and adopted the Glenn standard that such a conflict of interest is to be “weighed as a factor in determining whether there was an abuse of discretion.” (more…)

Category: 2nd, Claims Procedures, Claims Review, Conflict of Interest, MetLife v. Glenn | No Comments »
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Adam V. Russo | August 31, 2009

From The Bench – The Self-Insurer Volume 26* August 2009

By John H. Eggertsen, Esq. and Michael Friedman, Esq.

II. Fifth Circuit Rejects Benefit Decision For Procedural Defects; Can’t Even Assess If Determination was Arbitrary And Capricious

In Lafleur v. Louisiana Health Service Indemnity Company, d/b/a Blue Cross Blue Shield of La., 563 F.3d 148 (5th Cir. 2009), the Fifth Circuit found that Blue Cross Blue Shield of Louisiana (“BCBSL”) was so deficient in its substantive compliance with ERISA’s procedural regulations that it could not even express an opinion as to whether the determination was arbitrary and capricious. (more…)

Category: 5th, Louisiana, MetLife v. Glenn | No Comments »
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Adam V. Russo | August 31, 2009

From The Bench – The Self-Insurer Volume 26* August 2009

By John H. Eggertsen, Esq. and Michael Friedman, Esq.

After the U.S. Supreme Court’s recent decision in Metropolitan Life Ins. Co. v. Glenn ___ U.S.___, 128 S. Ct. 2343 (2008), many circuit courts have been applying a magnifying glass to their prior standard of review decisions, and making whatever adjustments they feel are necessary in light of this most recent guidance. We have discussed some of those cases in the past, and may do so again if circumstances warrant. In this discussion, however, we turn to a notable trend that had been emerging pre-Glenn, is continuing unabated and may be accelerating post-Glenn – that trend is the tendency of the courts to examine in greater detail the actual evidence on which claims determinations are based and the administrators’ rationales for making their determinations based on that evidence. Even under an arbitrary and capricious standard of review, generally held to be the most deferential standard, the courts are more willing to take the administrators’ word at face value. In addition, courts are scrutinizing claim determinations with an eye towards ERISA’s procedural requirements, and striking down those that fail to comply. The two cases discussed here are clear evidence of both these trends. (more…)

Category: 6th, MetLife v. Glenn, Ohio | No Comments »
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Adam V. Russo | August 19, 2009

The number of cases that apply the Supreme Court’s opinion in Metropolitan Life Insurance Company v. Glenn, 128 S. Ct. 2343 (2008) , when reviewing a decision to deny employee benefits by an administrator with a conflict of interest, continue to grow. The most recent example is Raybourne v. Cigna Life Insurance Company of New York, No. 08-2754 (7th Cir. 2009), where the plaintiff was a participant in his employer’s long-term disability benefits plan. (more…)

Category: 7th, Conflict of Interest, ERISA, MetLife v. Glenn | No Comments »
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Adam V. Russo | May 20, 2009

Estate of Schwing v. Lilly Health Plan, 2009 WL 989114 (3rd Cir. 2009)

The circuit courts continue to address the U.S. Supreme Court’s Glenn decision on the standard of review applicable in ERISA benefits litigation. The more deferential standard applies if the plan document gives the plan decision maker “discretionary” authority to make benefit decisions. In Glenn, the Supreme Court held that a decision maker’s conflict of interest does not change the standard of review, but must be considered as a factor when applying the abuse of discretion standard. (more…)

Category: 3rd, 8th, MetLife v. Glenn | No Comments »
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Adam V. Russo | May 13, 2009

The Ninth Circuit, in Daic v. Hawaii Pacific Health Group Plan for Employee of Hawaii Pacific Health, No. 06-17324, 2008 WL 3862074 (9th Cir. Aug. 13, 2008) analyzed whether MetLife, the insurer who administered the ERISA plan but was not a specifically names fiduciary, was nonetheless a plan fiduciary and whether, in light of Glenn the district court erred by inadequately considering MetLife’s structural conflict of interest. (more…)

Category: 11th, 9th, MetLife v. Glenn | No Comments »
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Adam V. Russo | September 5, 2008

The Supreme Court held in MetLife vs. Glenn that conflicted interests require a higher standard of review whenever the claims adjudicator and the claims financier were the same.  Thus, any claim contested in court will confer a significant advantage to the arrangement where the claims are adjudicated by an independent third party and paid by an independent employer.  This means a disadvantage where the claims are both adjudicated and paid by the same two parties, such as employer’s self-administered and self-funded plan or fully insured plans. (more…)

Category: 6th, ERISA, MetLife v. Glenn, Welfare Benefit Plans | 2 Comments »
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