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Knowing your rights and the requirements necessary in pursuing a claim if you have been denied benefits under an employee benefit plan are crucial. A recent case involving multiple Cigna entities, Connecticut General Life Insurance Company, and the NFL Player Insurance Plan shows how important this really is and why it matters to you.

The insurance companies and the NFL Player Insurance Plan are collectively seeking a little more than $1,000,000 in attorney fees following a lawsuit involving health benefit claims. The lawsuit, Advanced Physicians, S.C. v. Conn. Gen. Life Ins. Co. (case number 3:16-CV-2355-G), was filed in 2016 and is currently before the United States District Court for the Northern District of Texas. The Plaintiff in this case was Advanced Physicians, S.C., a medical facility that began treating retired NFL players in 2007. The NFL Player Insurance Plan provides medical benefits to both current and former NFL players. The insurance plan is governed by a federal law called the Employee Retirement Income Security Act of 1974. This Act is often shortened to “ERISA.”

After a lengthy 5-year litigation, the Court granted judgment in favor of the Defendants, who included both Cigna and the NFL Player Insurance Plan. The NFL plan designated insurance companies to be the administrator of the plan. Connecticut General Life Insurance Company and Cigna were both named administrators at various times under the plan. At the time of the lawsuit, Cigna processed claims submitted under the NFL plan and made determinations on whether to approve or deny health claims. Leading up to the lawsuit, Advanced Physicians, S.C. had submitted claims through the NFL plan on behalf of its patients. The lawsuit was filed by Advanced Physicians, S.C. after certain denials of health benefits occurred under the NFL plan.

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Bayer has been involved in lawsuits regarding Roundup since they acquired Monsanto in 2016, but the company is now facing increased pressure due to new cases of Non-Hodgkins Lymphoma in previous users. To combat the future legal challenge, Bayer has decided to set aside upwards of four billion dollars for incoming suits.

Bayer has also stated that it has undergone discussions of discontinuing the Roundup product line and replacing it with a safer alternative for non-commercial use. Roundup would still be available for commercial use. What is interesting about this case is that demonstrated the blurred lines between product effectiveness, product risk, and company responses to those risks. For example, the earliest Bayer could discontinue Roundup is 2023 – five years after the first Monstanto suits and the new medical research indicating its health risks.

The tendency among large companies to delay recognition of severe product risks in hopes of sales or minimized public relations impacts causes massive suffering for clients. For instance, Monsanto’s Bovine Growth Hormone and Roundup (among others), Johnson and Johnson hernia mesh patches, and a slew of other products (FDA) have all experienced issues that have later caused recalls. The FDA publishes a list of recalled products on a daily basis, many of which are classified as Type 1 recalls that pose a lethal risk to consumers.

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One concerning issue in society today is the ability of large corporations, companies, or conglomerates to operate outside legal boundaries through superior legal representation. This problem is highlighted by the Sackler family’s attempt to “obtain legal immunity through Purdue’s bankruptcy” (ABC News). Purdue Pharmaceuticals is a large, multi-national corporation that is best known for creating and over-distributing OxyContin, a powerful painkiller that causes addiction issues. Yesterday, it was released that U.S. Trustee William Harrington urged a New York federal bankruptcy court to deny Purdue’s long-awaited plan as it does not go far enough to remedy damages.

Purdue Pharma filed for Chapter 11 bankruptcy in 2019 following an onslaught of lawsuits stemming from the ongoing opioid epidemic in the United States. Through their exit, they aim to provide 4.3 billion in state funding for responding to the opioid crisis in exchange for “a release from all liability from all persons” involved in the thousands of lawsuits thrown the company’s way.

The claims are that Purdue Pharma broke numerous laws pertaining to advertising their products and pushing them into the market, namely the drug OxyContin. The company already plead guilty to three felonies in regard to their attempt to mislead federal authorities about their corporate marketing actions. Though 29 state attorneys general have supported Purdue’s plan of giving more than 4 billion to state governments, the U.S. Trustee’s Office has raised concerns regarding the legality and ethicality of Purdue and the Sackler’s plan to exchange assets for innocence. As of now, 39 states have signed onto the Purdue plan in hopes of receiving large financial assistance for handling their local opioid crises.

Happy Birthday to the Kentucky Unfair Claims Settlement Practices Act! Today marks the anniversary of the enactment of this important law in Kentucky. It holds insurance companies accountable for not paying claims fairly or promptly. With the right attorney on your side, they can be forced to pay all damages from the delay. They can be made to pay punitive damages for being too slow to pay.

We also extend a “thank you” to the lawmakers in our state who voted UNANIMOUSLY to pass this law. It is a uniform law passed in most states. Kentucky allows any claimant who has been treated unfairly to sue for damages. That threat, of being forced to pay for their misdeeds, keeps insurance payments flowing timely. It prevents unfair negotiation tactics and taking advantage of a person at their weakest.

Call Mehr, Fairbanks & Peterson today if you have been jerked around by an insurance company. We know what to do, and we get it done for you.

If you receive long-term disability (LTD) insurance as an employee benefit through work, it’s likely that your benefit is governed by the Employee Retirement Income Security Act, also known as ERISA. ERISA is a federal law that applies to all sorts of employee welfare benefits, including health insurance, life insurance, short-term disability insurance, and LTD insurance.

Very generally speaking, if you need to make a claim for LTD benefits, you will be required to go through a claim process with the insurance company. Here are five tips to help make sure you are providing the insurance company with the information it needs for your claim.

  1. Explain why you can’t work. This may seem obvious, but you will need to provide specific information about why you are unable to continue working. While an off-work note from your doctor might be sufficient for an excused absence with your employer, the insurance company may need additional information about why you can’t work. Be sure to gather and submit medical records and results from any diagnostic tests. Also, many insurance companies will provide you with fillable forms for you and your doctors to use to explain the basis of your disability.

  2. Make sure to get all your information submitted. It’s important to make sure you have provided the insurance company with all the information it needs to make a decision on your LTD claim. If your claim or appeal is denied, you may not be able to submit additional information after the decision is made. As a result, it is imperative to provide all medical and vocational records before the claim process is over.

  3. Pay attention to deadlines in letters from the insurance company. ERISA and its regulations set forth certain time limits for both you and the insurance company to follow during your LTD claim. If an insurance company denies your claim, it is required to give you notice of the amount of time you have to submit an appeal. Be sure to get your information submitted before the deadline passes.

  4. If the insurance company gives you an opportunity to submit information in response to a medical report it has obtained, take the opportunity to explain your claim. Insurance companies might hire their own doctors to either examine you or to perform a review of your medical records. If the insurance company provides you with a copy of the report before finalizing its decision on your claim, be sure to review the report and submit any additional information.

  5. Send in statements from co-workers or family members. Your medical records most often will have information about your medical conditions and why you are unable to work. If you have a co-worker or family member who can explain through firsthand knowledge how your medical conditions are affecting your ability to work or to complete activities of daily living, you can submit statements from those individuals in addition to your medical proof.

If you have questions about your long-term disability claim, contact the attorneys at Mehr, Fairbanks & Peterson. Philip Fairbanks, Esq., one of the partners at Mehr, Fairbanks & Peterson, wrote this piece. We hope this was helpful, and please get in touch with our firm if you have questions.

Most health insurance plans cover medical expenses if the treatment is medically necessary and not “experimental” or “investigational.” But the health insurance policy documents rarely spell out exactly what treatments the insurer considers experimental or investigational. Instead, health insurance companies will create separate “medical policy guidelines” that their claim examiners will use to approve or deny claims. These medical policies can result in a large number of claim denials if the insurance company has put in place a policy that denies all requests for a certain type of treatment.

If you get your health insurance coverage through your employer (or a family member’s employer), your insurance is likely subject to the Employee Retirement Income Security Act (ERISA). ERISA is a federal law that provides claimants and beneficiaries with a civil enforcement scheme to remedy wrongful denials of coverage.

Under ERISA, a claimant can file a lawsuit to enforce and/or clarify his rights to the benefits at issue. ERISA also allows a claimant to seek declaratory or injunctive relief if a particular medical policy is not consistent with current medical standards. In other words, if a medical policy is faulty and not based on prevailing medical standards, a claimant can ask a court to require the insurer to reprocess a claim using a corrected medical policy. This type of claim reprocessing is a common remedy under ERISA, and courts have the authority to order claim administrators to reprocess claims.

Allstate Employees sue Allstate Corporation and their 401k plans, alleging breach of fiduciary duties. The suit is based on the alleged poor performance of investment selections and expenses incurred. The case involves investments in six of the Focus Funds. The suit includes allegations against the plan fiduciary duties to diversify the investments of the plan to minimize the risk of large losses. Allstate representatives claim that plan fiduciaries must engage with a balancing of risks and returns, which is a function of portfolio management.

The plaintiffs allege that the Northern Trust Funds “consistently underperform” against the Morgan Stanley funds, which has drastically understated the value of company retirement savings plans. Allstate currently is defending the lawsuit, calming that the plaintiffs failed to exhaust administrative remedies before seeking resolution through litigation. Allstate raises questions about whether their 401k committee and their 401k administrative committee acted as fiduciaries concerning the conduct of which the plaintiffs complain. The case also revolves in a central fashion around the Employee Retirement Income Security Act of 1974 (ERISA), which the plaintiffs believe should have mandated Allstate to choose wiser and more lucrative investment options. Allstate, by contrast, believes that this case is a non-starter and is a matter of not losses, but complaints that there could have been more financial gain.

Mehr, Fairbanks & Peterson represent claimants in ERISA plans.

On June 8, 2021, Mehr, Fairbanks & Peterson obtained a judgment for $190,000 against Hartford Life and Accident Company in federal court. Hartford wrongfully denied life insurance benefits to a widow after her husband died of cancer, and accused them of making misrepresentations on the insurance application. The court disagreed and ordered Hartford to pay the full $190,000 face value of the life insurance policy.

Mehr, Fairbanks & Peterson has a strong record of closing life insurance cases and earning positive judgments for you or your family. If you or someone you know has had a life insurance claim denied, contact Mehr, Fairbanks & Peterson today.

Some car accidents are more complicated than others. Were you injured in a car wreck involving multiple vehicles? How do you determine who is at fault? Kentucky applies “pure comparative fault” when determining who is responsible for causing a collision. This means it is possible more than one person could be responsible for compensating you for your injuries. This also means that even if you are partially at fault yourself, you can still recover for your injuries, but only to the extent of the percentage liability of the other drivers.

For example, assume a car pulls out in front of you and you collide with it. Behind you, another driver is not paying attention and crashes into the back of your car. Each driver will be responsible for his or her percentage share of liability for your injuries, whether it is determined to be 50/50, 70/30, 90/10, or some other amount. A similar scenario could apply in a multi-party pile up, or a chain reaction rear-end collision.

What does this mean for you?

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