502(A)(1)(B) Claim for Benefits

:: District Court Rejects “Substantial Compliance” Argument As Justification For Failure To Exhaust Administrative Remedies

Defendants filed a Motion for Summary Judgment asking that Plaintiff’s Count I be dismissed for failure to exhaust administrative remedies. Plaintiff asserts that she substantially complied with the appeal process by telling Prudential over the phone that she wanted to appeal Prudential’s decision. In the alternative, Plaintiff alleges that Defendants did not provide her a …

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:: “Heightened Arbitrary And Capricious Review” Questioned After Glenn

The district court used the framework that we established in Williams v. BellSouth Telecommunications, Inc., 373 F.3d 1132, 1137-38 (11th Cir. 2004), which provides a six-step process “for use in judicially reviewing virtually all ERISA-plan benefit denials”:(1) Apply the de novo standard to determine whether the claim administrator’s benefits-denial decision is “wrong” (i.e., the court …

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:: “Unexplained Gap” In Reviewing Physician’s Opinion Results In Decision For ERISA Plaintiff

Based on our review of the record, these conclusions do not reflect a rational connection between the known facts and the decision to deny benefits. . . Unlike the cases the Plan relied upon in this case, an unexplained gap exists between Dr. Pollack’s report finding disability and his explanation for this finding and the …

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:: ERISA Claim Denial Sustained In Accidental Death Case Despite Lack Of Causal Proof

That it may be impossible to prove that Mr. Nally was indeed hypoglycemic at the moment of his accident does not mean that LINA’s decision does not survive moderately heightened arbitrary and capricious review. It was not unreasonable for LINA to conclude on the record before it that Mr. Nally’s accident was a result of …

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:: Disclaimer Shields Claims Administrator From Mispresentation Claims

Tenet alleges that it provided approximately $ 241,000 worth of medical services to Sylvester based on UniCare’s representation that Sylvester was covered under the Plan. . . .  Pursuant to the Managed Care Agreement, UniCare paid Tenet $ 132,827.34, the negotiated payment under the agreement, on July 27, 2005.  On August 5, 2005, Sheltering Arms …

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:: Ninth Circuit Requires Application Of Normal Summary Judgment Rules In Benefits Denial Review

We conclude that a district court must apply the traditional rules of summary judgment when examining evidence outside of the administrative record in an ERISA case, including the requirement that the evidence must be viewed in the light most favorable to the non-moving party. As the district court failed to apply the traditional rules of …

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