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

:: Sixth Circuit Applies Met Life v. Glenn Factors To Overturn ERISA Disability Benefit Denial

Here, DeLisle offers more than conclusory allegations of bias. Five of the six file reviewers Sun Life relied on were under regular contract with Sun Life. The record reveals that Sun Life’s in-house attorney told at least some of its medical file reviewers that DeLisle was “terminated for cause.” But that is not what Krandall …

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:: Eighth Circuit Requires Evaluation Of Conflict Factor As A Tiebreaker

Here the district court concluded Standard was operating under a conflict of interest, but found Hackett failed to prove a serious breach of fiduciary duty. Accordingly, the conflict of interest was not a factor in the district court’s review of Standard’s decision denying benefits. In light of the Supreme Court’s intervening decision in Metropolitan Life …

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:: Third Circuit Abandons “Sliding Scale” Approach In Judicial Review of ERISA Benefit Denials

Accordingly, we find that, in light of Glenn, our “sliding scale” approach is no longer valid. Instead, courts reviewing the decisions of ERISA plan administrators or fiduciaries in civil enforcement actions brought pursuant to 29 U.S.C. § 1132(a)(1)(B) should apply a deferential abuse of discretion standard of review across the board and consider any conflict …

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:: District Court Applies Tenth Circuit Weber Opinion In Affirming Benefit Denial

Although Plaintiff does not address whether Defendant’s conflict of interest influenced its decision, Plaintiff argues in its motion for summary judgment that Defendant failed to provide a full and fair hearing. Plaintiff states that there is no indication that any of the review team was a health care professional, and there is no indication what …

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:: Fiduciary Exception Eclipses ERISA Fiduciary’s Claim Of Attorney Client Privilege

As applied by the courts in cases brought under ERISA, the “fiduciary” exception to the attorney-client privilege “comes into play when . . . the administrator for an ERISA plan invokes the attorney-client privilege against the plan beneficiaries.” Lewis v. UNUM Corp. Severance Plan, 203 F.R.D. 615, 619 (D. Kan. 2001). “This fiduciary exception derives …

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:: District Court Holds That Potential Claim For Benefits Forecloses Other ERISA Relief

On September 13, 2006, Mr. Tebbetts consulted with a doctor because he was experiencing pain in his abdomen, and the doctor ordered a CT scan of Mr. Tebbetts’ abdomen. The doctor sought pre-approval from Defendants of the CT scan, but Defendants declined coverage. Several days later, Mr. Tebbetts was taken to the hospital where a …

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:: Third Circuit Takes Expansive View Of Preexisting Condition Exclusion

he implication from [the Plaintiff’s] argument is that he falls into the category of “a misdiagnosis or an unsuspected condition manifesting non-specific symptoms,” which under both McLeod and Lawson would not be demonstrative of a pre-existing condition. Contrary to Doroshow’s claims, however, the record plainly demonstrates otherwise. Based on his family history of ALS and …

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:: PHCS Rate Schedule Challenged In New Managed Care Litigation

Chaffin v. Humana (S.D. Tex.)  challenges Humana’s alleged use of the “Prevailing Healthcare Charges System” to establish rates of reimbursement for out of network providers.  The case is brought by members of Humana’s “National Point of Service” insurance plan, according to the complaint. The complaint alleges that Ingenix, a subsidiary of United Healthcare Group, operates …

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