Successful Legal Summaries

At Eric Buchanan & Associates, our team has helped many people fight denials of disability insurance, ERISA insurance, and similar insurance claims. Here is a sample of our successful cases.

 

ERISA does not always apply when an insurance company claims it gave a discount based on where the person worked:

Gooden v. Unum Life Insurance Company of America
181 F.Supp.3d 465 (E.D. Tenn. 2016).

We stopped Unum from winning its argument that ERISA should apply to our client’s case.  Unum wanted ERISA to apply because the rules under ERISA are usually better for an insurance company and if ERISA applied, Unum could force the case to be heard in federal court.  We won the argument, convincing the court that ERISA did not apply and the case should be sent back to state court.

Unum claimed that ERISA applied to our client’s policy, claiming the policy was offered through work, so it was an employee benefit, not a true individual policy.  Unum argued that because several employees who worked with our client paid for their insurance from a payroll deduction and Unum gave them a discount, that the insurance became an ERISA employee benefit.

The court disagreed with Unum that this turned the policy into an ERISA employee benefit because the employer itself did not offer the policy, nor did the employer negotiate the discount.  Because the discount was negotiated directly with the employees, not the employer, ERISA did not apply.

To learn more about Gooden v. Unum Life Insurance Company of America, see more.

LINA was unreasonable, and the court overturned the denial of benefits.  LINA should have had the claimant examined before rejecting a treating doctor’s opinion or making credibility determinations.  LINA was unreasonable to tell the claimant to file for social security but then to fail to get a copy of the decision and to ignore the finding by SSA.  LINA was also unreasonable to deny benefits for someone they found disabled without meaningful evidence of improvement.

Holt v. Life Insurance Company of North America
No. 1:13-CV-339, 2015 WL 1243529 (E.D. Tenn. March 18, 2015).

Our client, an engineering and construction project administrator, suffered from a medical condition that caused disabling pain and fatigue. The Life Insurance Company of North America (LINA) agreed she was disabled for about 18 months but then terminated her long term disability (“LTD”) benefits saying she had improved.

Disagreeing with LINA, the former project administrator hired our firm.  We appealed the denial under the appeal procedures in the policy, but LINA refused to change the decision.  We then sued LINA on behalf of our client under ERISA, the Employee Retirement Income Security Act of 1974.  ERISA applied because the LTD benefit were offered at work.

Once in court, we submitted briefs arguing that LINA’s decision to cut off the benefits was arbitrary and capricious.  (This is the test in many cases under ERISA; it means we had to prove LINA’s decision was not only wrong but was unreasonable).

We explained that more than one of our client’s doctors said that her condition caused restrictions and limitations that precluded her from working.  LINA was wrong to terminate her benefits based on a nurse case manager’s (not a doctor’s) report.  We also argued that it looked like LINA relied on minor indications in the record that LINA interpreted to show signs of improvement despite the treating doctors never deviating from their opinion that she was disabled.

After we appealed and submitted additional information from Ms. Holt’s doctors, LINA relied on the opinion of a rheumatologist LINA hired who never examined our client.  The doctor LINA hired told LINA wnt so far as to say there were not any restrictions or limitations. We argued LINA should not rely on a doctor who never examined the person, especially when the doctor’s opinion was so unreasonable it said the person had no limitations.

The court ultimately agreed with us that that LINA’s decision was unreasonable (technically called “arbitrary and capricious”) in the way it considered the claim. The court determined that LINA unreasonably relied on a non-treating doctor when the claimant had a medical condition that required a credibility determination.  Another reason the court found LINA to be unreasonable was for relying on the opinion of the doctor LINA hired when the opinion was so bad it “lacked substantive analysis.” The court also explained that the LINA doctor’s opinion “was grossly at odds with the treatment records” and treating doctor opinions.

The court additionally explained that LINA’s decision was unreasonable because it failed to substantively address the social security decision despite having required the claimant to apply for social security disability and knowing that she had won her social security disability benefits. LINA should have meaningfully considered the social security decision despite the fact the social security decision was not in the file; LINA knew about it and should have tried to get it to consider it.

To learn more about Holt v. Life Insurance Company of North America, see more.

Insurance companies should not reject a claim just because some of the person’s complaints are “subjective.” Insurance companies should not rely on non-examining doctors to evaluate someone’s credibility, especially where they have the right to have the person examined and choose not to.  Insurance companies should adequately consider treating doctors’ opinions.

Platt v. Walgreen Income Protection Plan for Store Managers
455 F.Supp.2d 734 (M.D. Tenn. 2006).

No. 3:05-0162, 2006 WL 3694580 (M.D.Tenn. Dec. 14, 2006).

Our client had a MetLife long term disability (LTD) policy at work. When she became disabled, MetLife paid benefits for a short time but then decided to stop paying.  She appealed, hired us, and we eventually sued on her behalf.

Because the LTD benefits were offered at work, this case fell under ERISA, the Employee Retirement Income Security Act of 1974. MetLife had included language in its policy saying it had discretion so that under ERISA, the court reviewed the case under an “arbitrary and capricious” standard of review; this means that the insurance company only has to be reasonable, even if they are wrong. Platt v. Walgreen Income Prot. Plan for Store Managers, 455 F. Supp. 2d 734, 743 (M.D. Tenn. 2006).

Despite agreeing with MetLife that the court did not have to consider information submitted to MetLife after our client had used up all her appeals, the court still found that MetLife’s decision-making process was so wrong that it was arbitrary and capricious and overturned the denial. Id., at 747.

MetLife argued that our client’s records did not have “objective indicators that” our client’s “medical condition preclude[d] [our client] from engaging in ‘any gainful occupation,’ ” which was the test under the policy.  Id, at 744.  MetLife relied on cases saying that they could deny the claim because the claimant made “subjective complaints.”  The court rejected that argument, pointing out that, in the cases, MetLife attempted to rely on, the person did not even have a firm diagnosis of the condition, while in this case, two doctors confirmed the diagnoses.

The court then explained that the important consideration was whether MetLife was reasonable to reject the opinion of our client’s treating physician in favor of two doctors MetLife hired to review the medical records. Id, at 744. “A Claims Administrator may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.” Platt v. Walgreen Income Prot. Plan for Store Managers, 455 F. Supp. 2d 734, 745 (M.D. Tenn. 2006), citing Black & Decker Disability Plan v. Nord, 538 U.S. at 834, 123 S.Ct. 1965 and Smith v. Continental Cas. Co., 450 F.3d 253, 262 (6th Cir.2006). “And the consulting physicians hired by the Claims Administrator to review the file may not make credibility determinations concerning the claimant’s subjective complaints without the benefit of a physical examination.” Platt, 455 F. Supp. 2d at 745, citing Smith, 450 F.3d at 263.  Therefore, “under Nord, MetLife was not required to give deference to [the treating doctor’s] opinion over the opinions of its own consulting physicians. But MetLife’s consultants were not free to discredit Plaintiff’s subjective complaints of pain or its impact on her physical capacity without a physical examination.”  Platt, 455 F. Supp. 2d at 745, citing, Smith, 450 F.3d at 262–263.

MetLife’s decision to rely on its on non-examining doctors’ opinions about the claimant’s complaints was especially wrong because MetLife had the right to have the claimant examined by a doctor under the rules in the policy.  The refusal to get such an exam “supports the conclusion that MetLife’s decision to deny benefits was arbitrary and capricious, particularly when MetLife’ s conflict of interest is taken into account.” Id., at 746–47.

The court ultimately agreed with us and concluded that MetLife had acted arbitrarily and capriciously in denying the claim.  MetLife should not have rejected our client’s complaints simply because she made subjective complaints, should not have relied on their own doctors without properly considering the treating doctors, should not have relied on their doctors opinion as to the claimants credibility, especially when the policy allowed the claimant to be examined by a doctor of their choice.  While the court said MetLife’s decision was wrong, the court did not award benefits but remanded to MetLife to reconsider and to consider the evidence it did not look at before.

To learn more about Platt v. Walgreen Income Protection Plan for Store Managers (and MetLife), see more.

Nissan, as Plan Administrator of our client’s LTD plan, ordered to pay a penalty for failing to turn over plan document after we requested them.

Dies v. Provident Life & Accident Insurance Company
No. 3:04-CV-0113, 2006 WL 208878; 37 Employee Benefits Cas. (BNA) 2364, (M.D.Tenn. Jan. 25, 2006).

We sued Provident, a Unum company, for failing to pay our client’s benefits.  We also sued Nissan, her employer that offered the long term disability (LTD) benefits, because Nissan refused to provide us copies of our client’s plan documents.

After Provident denied our client’s benefits and she hired us to help her, we asked her employer, Nissan, for a copy of her long term disability policy.  Even though we wrote several letters, Nissan failed to provide us a copy of the policy.  After we appealed the denial of our client’s benefits and Unum refused to pay, we sued both for the benefits and for Nissan’s failure to turn over plan documents.  In our lawsuit we pointed out to the court that Nissan still had not provided the documents.

We sued Nissan for failing to provide the documents because ERISA also has a rule that the plan administrator of an employee benefit plan (usually the employer) has to provide copies of any plan documents, like an LTD policy, within 30 days of a written request.  If the plan administrator fails to provide the document within 30 days, a court can make the plan administrator pay up to $110 per day for any day after 30 days the documents are not provided.

As this case went on, Provident and our client settled the claim for benefits, but we continued to pursue the claim for penalties for the failure to provide plan documents. The court awarded our client $28,650 in penalties for Nissan’s failure to provide the plan documents.

To learn more about Dies v. Provident Life & Accident Insurance Company, see more.

Discovery in an ERISA case permitted into an insurance company’s bias, conflict of interests, and unfair claims handling practices:

Bennett v. Unum Life Insurance Company of America
321 F. Supp. 2d 925 (E.D. Tenn. 2004).

This order was one of the first rulings in an ERISA case that a court agreed to order an insurance company to give up information about its unfair claims’ practices.

When a case is in court, normally parties learn information about the other side during a process called “discovery.,” But in ERISA cases, courts have limited discovery, saying parties can only get the information in the claim file that was relied on or submitted to the insurance company.  We successfully argued that there should be an exception to the “no discovery” rule when attorneys for disabled claimants are seeking information about the way insurance companies like Unum have internal policies and procedures that encourage their claims handlers to deny claims.

Prior to this case, the Supreme Court and the Court of Appeals for the Sixth Circuit had suggested that discovery into the insurance company’s bias and conflict of interest might be permitted.  This was one of the first cases to address what an attorney has to show in order to get this type of discovery; it was also one of the first cases to actually get an order allowing for discovery of information into the biased procedures of an insurance company.

One question was whether courts would allow this discovery just by saying the insurance company was biased or whether attorneys would need to show the court some information to make the discovery reasonable.  In this case, the court said that we needed to show some information that suggested the discovery was reasonable.  The court then held we had provided enough information to show the discovery was reasonable and ordered Unum to answer some discovery into the company’s biased claims handling.  (Some later cases have held that such initial showing is not required, but other courts still require an initial showing.)

To learn more about Bennett v. Unum Life Insurance Company of America, see more.

Unum wrongfully tried to apply a shorter appeal deadline than was in the plan:

Knight v. Provident Life and Accident Insurance Company

not reported in F. Supp. 3d (2014), 2014 WL 1280278

Unum paid long term disability (LTD) benefits for almost 12 years before denying benefits in 2012.  When Unum denied the claim, Unum gave 90 days to appeal.  Our client’s previous attorney failed to appeal within 90 days.  The client left his previous attorney after that and hired us.  We filed an appeal after we took over the case, which was after about 123 days from the denial. This issue in this case was whether this appeal was on time or late.

Because our client became disabled before January 1, 2002, Unum argued that an older version of the ERISA claims regulations applied.  Under those regulations, Unum only had to allow 60 days to appeal; they argued they gave even more time by giving 90 days.  The Department of Labor issued new claims regulations while Unum was paying this claim that allowed for 180 days to appeal, but those regulations were only effective to claims filed after January 1, 2002, so arguably did not apply to this claim.

However, while benefits were being paid, the LTD benefits plan and insurance policy was updated to reflect the new claims regulations, so the LTD plan said someone who was denied had 180 days to appeal.  The court agreed with us that because that was the plan provision in place when the claim was denied, that plan provision controlled, so Unum should have given 180 days to appeal.  Because the appeal was filed in 123 days, less than the 180 days under the plan, the appeal was timely.  The court denied Unum’s motion to uphold its denial, granted out motion, and ordered Unum to consider the appeal timely filed.

To learn more about Knight v. Provident Life and Accident Insurance Company, see more.

Carty v. Metro. Life Insurance Company
No. 3:15-CV-01186, 2017 WL 660680 (M.D. Tenn. Feb. 17, 2017).

No. 3:15-CV-01186, 2016 WL 7325334 (M.D. Tenn. December 15, 2016).

Temponeras v. United States Life Insurance Company of America
185 F.Supp.3d 1010 (S.D. Ohio 2016).

Gooden v. Unum Life Insurance Company of America
181 F.Supp.3d 465 (E.D. Tenn. 2016).

McAlister v. Liberty Life Assurance Company of Boston
647, Fed. Appx. 539 (6th Cir. 2016).

No. 14-22-DLB-HAI, 2015 WL 4529297 (E.D. Ky. July 27, 2015).

Harris-Frye v. United of Omaha Life Insurance Company
No. 1:14-CV-72, 2015 WL 5562196 (E.D. Tenn. September 21, 2015).

No. 1:14-CV-72, 2015 WL 5562193 (E.D. Tenn. June 1, 2015).

Strickland v. Merck & Co., Inc.
No. 3:13-CV-01085, 2015 WL 1311737 (M.D.Tenn. March 23, 2015).

Hammonds v. Aetna Life Insurance Company
No. 2:13-CV-310, 2015 WL 1299515 (S.D. Ohio, March 23, 2015).

Rainey v. Sun Life Assurance Company of Canada
Order on Remedies, No. 3:13-CV-0612, 2014 WL 7156517 (M.D. Tenn. Dec.15, 2014)
Order adopting R&R, No. 3:13-CV-0612, 2014 WL 4979335 (M.D.Tenn. Oct. 6, 2014)
Report and Recommendation, No. 3:13-CV-0612, 2014 WL 4053389 (M.D.Tenn. Aug. 15, 2014).

Bailey v. United of Omaha Life Insurance Company
No. 13-CV-02996 SHL, 2014 WL 5822846 (W.D. Tenn. November 10, 2014)

938 F. Supp. 2d 736 (W.D. Tenn. 2013).

Knight v. Provident Life and Accident Insurance Company
No. 3:12-CV-01226, 2014 WL 1280278 (M.D. Tenn. March 27, 2014).

No. 3:12-CV-01226, 2014 WL 460018 (M.D. Tenn. February 05, 2014).

Jensen v. Aetna Life Insurance Company
32 F.Supp.3d 894 (W.D. Tenn. 2014).

Kasko v. Aetna Life Insurance Company
33 F.Supp.3d 782 (E.D. Ky. 2014).

Brown v. Federal Express Corporation
62 F.Supp.3d 681 (W.D. Tenn. 2014).

McClain v. Eaton Corporation Disability Plan
740 F.3d 1059 (6th Cir. 2014).

Neaton v. Hartford Life & Accident Insurance Company
517 Fed. Appx. 475 (6th Cir. 2013) (Unpublished).

Satterwhite v. Metropolitan Life Insurance Company
803 F. Supp. 2d 803 (E.D. Tenn. 2011)
Report and Recommendation, No. 1:06-CV-165, 2008 U.S. Dist. LEXIS 112854 (E.D. Tenn. July 7, 2008) and
Order adopting R & R, No. 1:06-CV-165, 2008 WL 2952473 (E.D. Tenn. July 29, 2008)
No. 1:06-CV-165, 2007 WL 2746886 (E.D. Tenn. Sept. 19, 2007).

Mulligan v. Provident Life & Accident Insurance Company
271 F.R.D. 584 (E.D. Tenn. 2011).

McKay v. Reliance Standard Life Insurance Company
428 Fed. Appx. 537 (6th Cir. 2011) (Unpublished).

654 F. Supp. 2d 731 (E.D. Tenn. 2009).
No. 1:06-CV-267, 2007 WL 2897870 (E.D. Tenn. September 28, 2007).

Stellas v. BWXT Y-12, LLC
3:04-CV-7, 2005 WL 2097796 (E.D.Tenn. August 29, 2005).

Walsh v. Metropolitan Life Insurance
No. 3:06-1099, 2010 WL 1609494 (M.D. Tenn. Apr. 20, 2010).

3:06-1099, 2009 WL 603003 (M.D. Tenn. Mar. 9, 2009).

Frassrand v. Metropolitan Life Insurance Company
No. 1:07-CV-222, 2010 WL 1252817, (E.D. Tenn. March 24, 2010).

1:07-CV-222, 2009 WL 6313560 (E.D.Tenn. June 1, 2009).

Rannigan v. Long Term Disability Insurance for Employees of Schwan’s Shared Services
No. 1:08-CV-256, 2009 WL 1362045 (E.D. Tenn. May 13, 2009).

Smith v. Bayer Corporation Long Term Disability Plan
No. 3:04-CV-128, 2009 WL 676774 (E.D. Tenn. Mar. 11, 2009).

275 Fed. Appx. 495 (6th Cir. 2008) (Unpublished).

Kinsler v. Lincoln National Life Insurance Company
660 F. Supp. 2d 830 (M.D. Tenn. 2009).

Goetz v. Greater Georgia Life Insurance Company
649 F. Supp. 2d 802 (E.D. Tenn. 2009).

Molodetskiy v. Nortel Networks Short Term & Long Term Disability Plan
594 F. Supp. 2d 870 (M.D. Tenn. 2009).

Cooper v. Life Insurance Company
No. 1:05-CV-111, 2008 WL 819990 (E.D.Tenn. Mar. 25, 2008).

486 F.3d 157 (6th Cir. 2007).

Wells v. Unum Life Insurance Company of America
593 F. Supp. 2d 1303 (N.D. Ga. 2008).

Myers v. Prudential Insurance Company of America
581 F. Supp. 2d 904 (E.D. Tenn. 2008).

No. 4:03-CV-60, 2005 WL 1240603 (E.D.Tenn. March 1, 2005).

Warden v. Metropolitan Life Insurance Company
574 F. Supp. 2d 838 (M.D. Tenn. 2008).

Schlachter v. Life Insurance Company of North America
No. 3:05-CV-296 , 2007 WL 128326 (E.D.Tenn. Jan. 11, 2007).

Bradford v. Metropolitan Life Insurance Company
No. 3:05-CV-240, 2007 WL 956640 (2007) (unreported)

514 F.Supp.2d 1024 (E.D.Tenn. 2007).
No. 3:05-CV-240, 2006 WL 1006578, (2006) (unpublished)

Platt v. Walgreen Income Protection Plan for Store Managers
No. 3:05-0162, 2006 WL 3694580 (M.D.Tenn. Dec. 14, 2006)

Hall v. Baker Hughes Inc. Long Term Disability Plan
No. 2:05-CV-63, 2006 WL 270283 (E.D.Tenn. February 2, 2006).

Williamson v. Unumprovident Corporation
Nos. 1:04-CV-162,1:04-CV-163, 2005 WL 6731769 (E.D.Tenn. Oct. 21, 2005).

Webber v. Aetna Life Insurance Company
375 F. Supp. 2d 663 (E.D. Tenn. 2005).

Green v. Prudential Insurance Company of America
383 F. Supp. 2d 980 (M.D. Tenn. 2005).

Potter v. Liberty Life Assurance Company
132 Fed. Appx. 253 (11th Cir. 2005) (Unpublished).

Addison v. Hartford Life & Accident Insurance
No. 1:03-CV-172, 2003 WL 23413737 (E.D.Tenn. December 12, 2003).

Kilpatrick v. Intertrade Holdings, Inc.
No. 1:02-CV-173, 2003 WL 21938912; 31 Employee Benefits Cas. (BNA) 1984, (E.D.Tenn. July 7, 2003).

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