Welfare Benefit Plans

:: “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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:: Sixth Circuit Opinions Applying Estoppel In ERISA Cases – An Anthology

Estoppel under ERISA is an equitable doctrine of the federal common law of contracts designed to enforce ERISA and the agreements made under it. Armistead v. Vernitron, 944 F.3d 1287, 1298 (6th Cir. 1991). There are five elements to an estoppel claim under ERISA: (1) a representation of fact made with gross negligence or fraudulent …

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:: District Court Adopts Agency Principles Deeming Employer Agent Of Insurance Carrier

n Ward v. Management Analysis Co. Employee Disability Benefit Plan, the Ninth Circuit cited with approval a decision under California law finding an agency relationship where an employer administers a group insurance policy while under the control and direction of the insurer. According to the Elfstrom rule, a dispositive factor is proof that the employer …

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:: The Conflict Between ERISA Overpayment Claims And Statutory Protection Of SSDI Benefits

he plaintiff also argues for dismissal of the counterclaim because MetLife seeks to recover funds received under the Social Security Act, which funds are protected from “execution, levy, attachment, garnishment, or other legal process.” See 42 U.S.C. § 407. For support, the plaintiff cites Ross v. Pa. Mfrs. Ass’n Ins. Co., No. Civ.A 1:05-0561, 2006 …

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:: Failure To Remit Health Insurance Premiums Punishable Under 18 U.S.C. 664

Failure to remit withheld wages for health insurance premiums can lead to several serious consequences for the plan fiduciaries.    The  criminal prosecution of this conduct typically occurs under 18 U.S.C. 664. The elements of a Section 664 embezzlement claim include: (1) the unauthorized; (2) taking or appropriation; (3) of union benefit plan funds; (4) …

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:: HealthNet’s Benefit Denial Based Upon Lack Of Medical Necessity Rejected

he district court concluded that a remand was futile because the Wieners did not show that Jonathan was eligible for GHT under the standards described in IPRO’s decision, which the parties call “the FDA standard.” It is unclear whether the FDA standard defines what is “medically necessary” under the policy. The policy provides, inter alia, …

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