Standard of Review

:: “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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:: 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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:: Thorny Issues Presented In Grants Of Discretion To Benefit Administrators

“As an independent, non-fiduciary, third-party administrator, Everest might still be liable . . . if the Geddesses had made claims against Everest individually, distinct from its role as United’s agent. But they did not. Nor did the district court find any basis for personal liability against Everest. For these reasons, the money judgment [on the …

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:: Strategic Decisions In Pleading (And Defending) Provider Reimbursement Claims – A Case Study

St. Luke’s may amend within thirty days. If St. Luke’s amends to assert an ERISA claim, the personal jurisdiction issue is far simpler.  “[U]nder ERISA’s nationwide service of process provision,” 29 U.S.C. § 1132(e)(2), “[a] court may exercise personal jurisdiction over the defendant if it determines that the defendant has sufficient ties to the United …

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:: Controversy Over Provider Reimbursement Rates Points To Additional Investigations

Cuomo said his year-long investigation is far from over.  Ingenix “is only the first step,” he warned. “I’m putting all other health insurance companies on notice today.” “AG Andrew Cuomo reins in health care giant United on price fixing; systemic overcharging revealed”, New York Daily News, January 13, 2009 The New York Attorney General today …

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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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