Newport Beach ERISA Claims Denials

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ERISA Plans often fill two critical roles in the claims administration process – issuing claims decisions and paying benefits. This creates a structural conflict of interest between a Plan and its insureds (or beneficiaries), as the plan administrator has a financial incentive to prioritize its own interests. If the plan administrator does so, it may be abusing its discretion and its decision may be overturned. If your ERISA claim is improperly denied, you may be able to recover your benefits, interest on the benefits due and attorneys’ fees.

A plan administrator may abuse its discretion by:

  • Placing greater weight on a “paper review” of the insured’s medical records than the reports of treating physicians. Montour v. Hartford Life & Accident, 588 F.3d 623, 630 (9th Cir. 2009).
  • Relying on an exclusionary clause which is not conspicuous, plain and clear to the insured.Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 386-87 (9th Cir. 1994).
  • Unreasonably delaying or withholding benefits due under the policy. See 29 C.F.R. § 2560.503-1 (f)(1); 29 C.F.R. § 2560.503-1 (i)(1).
  • Requiring “objective” medical evidence of complaints that are inherently subjective. Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 635 (9th Cir. 2009); Hagerty v. American Airlines Long Term Disability Plan, 2010 U.S. Dist. LEXIS 91995 (N.D. Cal. Sept. 3, 2010).
  • Discontinuing disability benefits without substantial evidence of improvement. Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 871 (9th Cir. 2008).
  • Ignoring the Social Security Administration’s finding of disability. Sterio v. HM Life, 2010 U.S. App. LEXIS 4615 (9th Cir. Mar. 4, 2010)
  • Failing to engage in a “meaningful dialogue” with the claimant, by explaining the basis for the denial in clear language with specific references to the plan provisions that form the basis its denial.  Booton v. Lockheed, 110 F.3d 1461 (9th Cir. 1997).

If your ERISA claim was improperly denied, you should seeking legal help immediately, because federal law or your policy terms may limit the time you have to file a suit. Attorneys experienced in handling ERISA denials can help you appeal or litigate the insurance company’s decision and inform you of any applicable deadlines.

McKennon Law Group PC represents policyholders and ERISA claimants on a contingency-fee basis, meaning we do not recover unless we obtain a favorable settlement, judgment or verdict at trial for your case.

Call or email us for a free consultation.

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