Medical Proof Required to Deny ERISA Claims Based on Intoxication Exclusion Says Fifth Circuit

Many ERISA plans and insurance policies contain provisions excluding coverage for losses caused by the insured's intoxication.  In cases where the plan or insurer asserts such an exclusion, the question becomes what evidence must the insurer put forward in order to prove the insured was intoxicated and the exclusion applies? The U.S. Court of Appeals …

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ERISA Plan Cannot Recover Overpayments Resulting From The Plan’s Own Mistake

Most employee benefit plans (e.g., employer-sponsored health or disability insurance) allow the plan to recover excess overpayments it provides the insured.  This typically occurs where the plan provides benefits that are duplicated by another source of funding.  For instance, most long-term disability plans provide that benefit payments are offset by amounts the insured receives from …

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Health Plans Can’t Discriminate Against Mental Health Treatment Says Ninth Circuit

Among the challenges of a mental health condition is the difficulty persuading health insurers to cover treatment.  Mental health conditions can be difficult to objectively diagnose and can require lengthy and expensive treatment often with little prospect of a conventional "cure."  Hence, health plans have a powerful incentive to minimize coverage for mental health conditions …

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ERISA Appeal FAQs

ERISA, the federal law governing most employer-sponsored benefits (e.g., health, disability or life insurance, or pension or retirement benefits) gives participants the right to appeal the Plan or insurer's denial of payment or benefits (in legalese, an "adverse benefit determination").  Plans and insurers are required to be transparent about participants' appeal rights.  Unfortunately, adverse benefit …

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Court of Appeals Clarifies Policy Causation Language In Favor Of The Insured

When language in one part of your ERISA policy says your claim is covered, can the company rely on language elsewhere in the policy to deny your claim?  The Ninth Circuit Court of Appeals recently answered “no.”  In Dowdy v. Metropolitan Life Ins. Co., the court ruled the conflicting language about what caused the insured's …

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Can The Company Deny Your ERISA Claim “Because We Said So?”

Who decides whether a person’s entitled to coverage under an ERISA plan?  Given ERISA gives plan participants the right to take the company to court to dispute coverage denials, you might think the judge decides.  But the answer’s not that simple.  Often, the insurer itself can decide whether you’re covered under the terms of the …

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Insurance Regulators Investigating Aetna for Training Employees to Deny Coverage Without Reviewing Patient’s Medical Records

Aetna, the country’s third largest health insurer, is under investigation by state insurance regulators following Aetna’s admission that it routinely denies medical treatment coverage without reviewing the insured’s medical records. Aetna’s admission surfaced in a lawsuit by a California man who claimed Aetna improperly denied coverage for his medical treatment. The insured has a rare …

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