Employment benefits are an important consideration when seeking and accepting new employment, as well as remaining with an employer, and can be a significant source of support for employees both during their working years and after they retire. This is why it is so important to work with an experienced attorney when employment benefits are wrongly denied.
There are certain protections in place to ensure that employers and their insurers do right by employees when it comes to employment benefits. One important law is the Employee Retirement Income Security Act of 1974 (ERISA), a federal measure which sets minimum standards for private, voluntary pension and health plans managed by employers. One important goal of ERISA is to protect workers so that they are able to benefit in retirement from assets they put into employer-managed retirement plans. ERISA and the U.S. Department of Labor also establish requirements for processing claims for health and disability benefits, as well the rights of ERISA plan participants when claims are denied.
Established case law holds that, when an ERISA benefits plan administrator denies benefits to a plan participant, courts review the decision based on whether the administrator’s decision was “arbitrary and capricious.” In a recent case handled by our firm, such a review was made of an ERISA administrator’s decision to deny long-term disability benefits sought on behalf of a deceased employee who had been denied those benefits on the basis that she had a pre-existing condition.
Under the woman’s plan, disability benefits were not available for pre-existing conditions, which was defined as including injuries or sicknesses for which the employee received medical attention in the three months prior to becoming insured under the policy. At issue in the case was the timing of the employee’s symptoms and medical treatment for a shoulder injury, which began during the three month look-back period and ultimately developed into a diagnosis for stage IV lung cancer after the look-back period had ended.
In this case, we were successful in arguing that denial of benefits under the pre-existing condition provision was arbitrary and capricious since, among other things, neither the employee nor her providers were aware the symptoms they were treating would ultimately result in a diagnosis for lung cancer. The case is a good example of the kind of advocacy that an experienced employment law attorney can offer when the interpretation of contractual provisions is in dispute. Employees who find that they have been wrongfully denied benefits should always work with an experienced advocate to ensure their rights and interests under employer-sponsored benefits contracts receive the advocacy they are due.
Sources:
Robert Kaiser v. United of Omaha Life Insurance Company, 2016 WL 379814 (W.D. Wisconsin.)
United States Department of Labor, “Filing a Claim for Your Health or Disability Benefits,” Accessed March 30, 2016.
United States Department of Labor, “FAQs About Retirement Plans And ERISA,” Accessed March 30, 2016.
