Bain v. Oxford Health Insurance: Judge Finds Insurer Liable for Breach of Fiduciary Duty Under ERISA As Medical Necessity Guidelines Were Inconsistent With Medical Standards of Care

On Behalf of | Mar 4, 2020 | Disability Insurance, ERISA, ERISA - Abuse of Discretion, ERISA - Conflict of Interest, ERISA - Fiduciary Duty, ERISA - Standard of Review, Insurance Litigation Blog

In a recent decision by the U.S. District Court for the Northern District of California, Bain v. Oxford Health Insurance, 2020 WL 808236, the Court held that it is an abuse of discretion for an insurance company to rely on unreasonable medical necessity guidelines, to...

Tenth Circuit Finds that Policy Terms in an ERISA Plan Did Not Unequivocally Grant an ERISA Administrator Discretion to Interpret Plan Terms, Applies De Novo Review

On Behalf of | May 17, 2019 | Disability Insurance, ERISA, ERISA - Standard of Review, Firm News, Insurance Litigation Blog, Policy Interpretation

Insurance companies acting as ERISA plan administrators often are guilty of abusing their discretion to interpret policy language related to the level of benefits payable to a claimant under a long-term disability (“LTD”) policy in a manner most beneficial to them,...

Ninth Circuit Grants a Small Reprieve to the Abuse of Discretion Standard of Review, Ruling That Discretionary Language Provisions in Self-Funded ERISA Will Apply

On Behalf of | Aug 24, 2017 | Disability Insurance News, ERISA, ERISA - Abuse of Discretion, ERISA - De Novo Review, ERISA - Standard of Review, Firm News, Insurance Litigation Blog

When litigating ERISA-governed short-term disability, long-term disability, life and medical insurance claims, a major consideration is which “standard of review” will apply to the Court’s review of the insurer’s decision – abuse of discretion or de novo.  The de novo...

9th Circuit puts final nail in coffin for discretionary clauses in insurer-funded ERISA plans

On Behalf of | May 24, 2017 | Case Updates, Disability Insurance, Disability Insurance News, ERISA, ERISA - Abuse of Discretion, ERISA - De Novo Review, ERISA - Preemption, ERISA - Standard of Review, Firm News, Health/Medical Insurance, Insurance Litigation Blog, Life Insurance, Policy Interpretation

Disability and life insurers frequently include clauses in their insurance policies affording them complete discretion to decide whether a claim has merit.  The clauses usually state the insurer has total discretion to decide whether the claimant is eligible for the...

Robert McKennon Publishes Article: Ninth Circuit: ‘Independent’ Physicians may Favor Insurers

On Behalf of | Sep 8, 2016 | ERISA, ERISA - Abuse of Discretion, ERISA - Standard of Review, Firm News, Insurance Litigation Blog, Legal Articles, News Blog

In the September 8, 2016 edition of the Los Angeles Daily Journal, Robert McKennon of the McKennon Law Group published an article regarding the use of so-called “independent” physicians used by insurance companies as a pretense to deny valid claims. In the article...

With Discretionary Language Even Barred in Self-Funded ERISA Plans, is This the Death of The Abuse of Discretion Standard of Review In California?

On Behalf of | Oct 12, 2015 | Disability Insurance News, ERISA, ERISA - Abuse of Discretion, ERISA - De Novo Review, ERISA - Standard of Review, Firm News

Recently, we explained that District Courts within the state of California, applying California Insurance Code section 10110.6, ruled that, even if an insurance Plan contains language giving discretion to a claim administrator, that language is unenforceable, and de...

ERISA Disability Insurance Claimants Take Note – Discovery Is Allowed In De Novo Review Cases

On Behalf of | Sep 14, 2015 | Disability Insurance News, ERISA, ERISA - Abuse of Discretion, ERISA - De Novo Review, ERISA - Standard of Review

Well-intentioned policymakers enacted the Employee Retirement Income Security Act of 1974 (“ERISA”) over forty years ago to provide for the protection of participants’ employee benefits in part by establishing a uniform set of rules to ensure efficient proceedings. ...

Insurers Do Not Have Discretionary Authority, Absent Clear Language in Official Plan Documents

On Behalf of | Apr 30, 2015 | Case Updates, Disability Insurance, Disability Insurance News, ERISA, ERISA - Abuse of Discretion, ERISA - Administrative Record, ERISA - De Novo Review, ERISA - Standard of Review, Firm News, Insurance Litigation Blog, Insurance Questions and Concepts, Policy Interpretation

In actions brought under the Employee Retirement Income Security Act of 1974 (“ERISA”), two roads diverge in federal court—and the court’s choice regarding the applicable standard of review can make all the difference in the scope of permissible evidence.  If the...

Third-Party ERISA Administrator Abused Discretion by Denying Medical Coverage: A Tale of What Not to Do

On Behalf of | Sep 16, 2014 | ERISA, ERISA - Abuse of Discretion, ERISA - Administrative Record, ERISA - Conflict of Interest, ERISA - Fiduciary Duty, ERISA - Standard of Review, Firm News, Health/Medical Insurance

Sometimes an administrator so unashamedly abuses its discretion in handling an insurance claim that its actions constitute a textbook example of “what not to do” for other administrators and the ensuing decision provides a clear illustration of how courts apply an...

California District Court Rules That a Treating Physician’s Observations are “More Persuasive” Than a Paper Reviewer’s Contrary Opinions

On Behalf of | Feb 13, 2014 | Case Updates, Disability Insurance, Disability Insurance News, ERISA, ERISA - Standard of Review, Firm News, Insurance Litigation Blog

When reviewing a claim for disability insurance, insurers and other claim administrators often rely on the opinions of paid physicians to support their improper denial decisions.  For example, a disability insurance company will hire a doctor to conduct a “paper...