bhoffman | July 19, 2010
www.seethebenefits.com
There is a well-known saying among baseball fans that the “tie goes to the runner.” This is true under one baseball rule that provides that a batter is out if he or the base is tagged before he reaches first. It is not true, however, under another rule that provides that a runner is out [...]
Adam V. Russo | May 7, 2010
Yesterday, I presented on “Plan Compliance Issues” at Regional Care, Inc.’s annual forum, held at the Gering Civic Center in Gering, NE. With over 200 attendees, the forum was a great success.
Click here to see my entire PowerPoint presentation.
Adam V. Russo | December 8, 2009
Davis v. AK Steel Corp., 2009 WL 3853608 (W.D. Pa. 2009)
The trial court in this case found that an employer’s SPD hand-delivery process satisfied DOL regulations, which require that the process be reasonably calculated to ensure that recipients receive SPDs and likely to result in full distribution. The employer had denied an employee’s claim for [...]
Adam V. Russo | November 23, 2009
By TIM HULL
(CN) – An insurance company must award benefits to an Ohio man who lost his leg in a drunken motorcycle crash, the 6th Circuit ruled, because the incident falls within the broad definition of an “accident.”
Adam V. Russo | August 28, 2009
From the August 13, 2009 EBIA Weekly
Wiley v. Cendant Corp. Short Term Disability Plan, 2009 WL 1940780 (N.D. Cal. 2009)
The employee in this case was denied disability benefits and sued his employer’s plan. In this decision affecting only the standard of review to be applied in later proceedings, the employee asked the court for the [...]
Adam V. Russo | July 28, 2009
In Wenner v. Sun Life Assurance Co. of Canada, 482 F.3d 878 (6th Cir. 2007), the Sixth Circuit found that Sun Life’s failure to give plaintiff an opportunity to appeal the new grounds for its termination of his benefits violated ERISA’s notice requirements. The insurer initially terminated plaintiff’s benefits because he failed to provide requested [...]
Adam V. Russo | July 28, 2009
In Administrative Committee of the Wal-Mart Stores, Inc. v. Gamboa, 479 F.3d 538 (8th Cir. 2007), an ERISA plan administrator brought suit seeking equitable reimbursement from a plan participant who had received a settlement from a tortfeasor. Although the reimbursement provision was contained in an SPD for a health plan, the employer had no formal [...]
Adam V. Russo | July 28, 2009
In Daic v. Metropolitan Life Insurance Co., 458 F. Supp. 2d 1167 (D. Haw. 2006) the district court rejected each of plaintiff’s arguments challenging the validity of the plan’s reservation of discretionary authority. The court concluded that the plan’s discretionary language was clear and found it inconsequential that such language was in the certificate was [...]
Adam V. Russo | July 28, 2009
In MacLeod v. Proctor & Gamble Disability Benefit Plan, 460 F. Supp. 2d 340 (D. Conn. 2006) the administrator denied the participant’s application for benefits on the grounds that the claimed disability resulted from the participant’s prior military service and therefore was excluded from coverage. At oral argument, the administrator admitted that its decision was [...]
Adam V. Russo | July 28, 2009
In Thomas v. Reliance Standard Life Insurance Co., 487. F. Supp. 2d 697 (D.S.C. 2007), the court examined whether death by asphyxia from vomitus resulting from drug self-administration was an accident within the terms of an ERISA-governed policy. Reliance Standard denied benefits pursuant to the policy’s exception for losses caused by suicide or intentionally self-inflicted [...]
Adam V. Russo | July 28, 2009
In Bond v. Ecolab, Inc., 2007 WL 551595 (E.D. Mich. Feb. 21, 2007, an ERISA plan participant died while engaging in autoerotic asphyxiation. The police and medical examiners concluded that the participant’s death was accidental. The plan’s claims administrator, MetLife, denied the beneficiary’s claim for benefits based on the plan’s exclusion for self-inflicted injuries. In [...]
Adam V. Russo | July 28, 2009
In Eckelberry v. Reliastar Life Insurance Co., 469 F.3d 340, the Fourth Circuit affirmed the insurer’s determination that the decedent’s fatal automobile collision did not qualify as an “accident” as defined under the subject ERISA plan. The insured died after he lost control of his car and collided headlong into the rear of a tractor [...]
Adam V. Russo | July 23, 2008
Diamond Crystal Brands, Inc. v. Wallace, 531 F.Supp.2d 1366 (N.D. Ga.2008)
After the negligent medical care and consequential death of Deborah Hayes, the Estate and her daughter Tamara Hayes pursued a wrongful death claim against the hospital. In Georgia State Court plaintiffs settled for $900,000, of which $837,000 went to Tamara Hayes and $63,000 to the [...]
Adam V. Russo | June 9, 2008
Cooper v. Premera Blue Cross, Slip Copy, 2008 WL 2180148 (W.D.Wash.) (May 23, 2008) addresses a risk often overlooked by plan participants when debating over their benefit plan’s right of reimbursement from other liable insurance carriers.
Cooper suffered multiple injuries while he was a passenger involved in an ATV accident and applied for benefits through his [...]
Adam V. Russo | November 13, 2007
The United States District Court for the Eastern District of Texas recently presided over a case involving a plan’s denial of claims due to a lack of signed subrogation agreement. Don Burgett, Et. Al. v. MEBA Medical and Benefits Plan, 2007 U.S. Dist. LEXIS 70934, (September 25, 2007). The Plan in this case lost, and [...]
