Creitz & Serebin LLP is counsel for plaintiff-appellants in two appeals pending before the Ninth Circuit, both of which will have oral arguments heard in March 2016.
In one, Anderson v. Sun Life, the Ninth Circuit will be deciding whether, in the face of ambiguous language in a long term disability policy, the plan's insurer can deny benefits to a career operating room nurse on the basis that she ceased to be a nurse when the hospital where she worked gave her a temporary light duty job as an accommodation to her injury.
The second, Upadhyay v. Aetna, asks the court to decide two issues:
First, does the Ninth Circuit's holding in Harlick v. BCBS (that plan insurers waive all defenses to the payment of benefits not raised during the administrative process) apply to a settlement agreement between the participant and her employer, when the insurer always knew of the existence of the settlement, but failed to raise it until after litigation had commenced; and
Second, in light of the Supreme Court's decisions in Heimeshoff v. Hartford and UNUM v. Ward, can an ERISA fiduciary insurer enforce a contractual limitations period contained in its insurance policy that
(1) violates the California Insurance Code;
(2) was not disclosed at any point during the administrative process; and
(3) would nullify the California notice-prejudice rule (something that the Supreme Court in UNUM v. Ward said it would make "scant sense" to permit insurers to do).
If you find yourself struggling with your ERISA plan's administrator or insurer over your benefits (pension, disability, health, or otherwise), let us see if we can help.
Sunday, December 20, 2015
Saturday, December 19, 2015
Another Big Win at the Ninth Circuit for ERISA Participants and Beneficiaries
In 2014, a unanimous 3-judge panel of the Ninth Circuit ruled in favor of Creitz & Serebin's clients in their appeal from the District Court of Arizona. Spinedex v. United, 770 F.3d 1282 (9th Cir. 2014), cert. denied, 136 S. Ct. 317 (2015). Among the issues that the Ninth Circuit addressed were these:
- Where a healthcare provider sues for ERISA-regulated benefits pursuant to an assignment from the patient/plan-beneficiary, there is no requirement for the provider to send a balance bill to the patient in order for the provider to have standing to sue under Article III of the U.S. Constitution. It seems like a simple and obvious point, but a number of courts had gone sideways on this question and the Ninth Circuit got it right.
- The Ninth Circuit reemphasized its earlier holding from Harlick v. Blue Shield of California, which had held that an ERISA claims administrator waives (and therefore cannot assert in litigation) any defenses to the payment of benefits that it failed to assert during the administrative process.
- The Claims Regulation propounded by the United States Secretary of Labor has long provided that the failure of a claims administrator to adhere to the regulations requirements results in "deemed denial" -- i.e., the participant can go straight to court if the administrator fails to follow the regulation. The Ninth Circuit held that administrators' failure to comply with this regulation can be no more than de minimis, effectively requiring strict compliance with the regulation (the insurer had sought a "substantial compliance" standard that would have severely disadvantaged participants and beneficiaries).
- The Ninth Circuit expanded on its earlier unanimous en banc holding in my case Cyr v. Reliance, to hold that proper party defendants under ERISA section 502(a)(1)(B) also include claims administrators. (I posted previously about this case when the Ninth Circuit issued its opinion).
On that last issue, the insurer sought certiori from the United States Supreme Court, which the Supreme Court denied on October 13, 2015. Spinedex v. United, 770 F.3d 1282 (9th Cir. 2014), cert. denied, 136 S. Ct. 317 (2015).
Along with Cyr, was another landmark ERISA decision from the Ninth Circuit that Creitz & Serebin secured along with our co-counsel, Joe Garofolo. Here's a link to the Ninth Circuit's Decision. If you find yourself struggling with your ERISA plan's administrator or insurer over your benefits (pension, disability, health, or otherwise), let us see if we can help.
- Where a healthcare provider sues for ERISA-regulated benefits pursuant to an assignment from the patient/plan-beneficiary, there is no requirement for the provider to send a balance bill to the patient in order for the provider to have standing to sue under Article III of the U.S. Constitution. It seems like a simple and obvious point, but a number of courts had gone sideways on this question and the Ninth Circuit got it right.
- The Ninth Circuit reemphasized its earlier holding from Harlick v. Blue Shield of California, which had held that an ERISA claims administrator waives (and therefore cannot assert in litigation) any defenses to the payment of benefits that it failed to assert during the administrative process.
- The Claims Regulation propounded by the United States Secretary of Labor has long provided that the failure of a claims administrator to adhere to the regulations requirements results in "deemed denial" -- i.e., the participant can go straight to court if the administrator fails to follow the regulation. The Ninth Circuit held that administrators' failure to comply with this regulation can be no more than de minimis, effectively requiring strict compliance with the regulation (the insurer had sought a "substantial compliance" standard that would have severely disadvantaged participants and beneficiaries).
- The Ninth Circuit expanded on its earlier unanimous en banc holding in my case Cyr v. Reliance, to hold that proper party defendants under ERISA section 502(a)(1)(B) also include claims administrators. (I posted previously about this case when the Ninth Circuit issued its opinion).
On that last issue, the insurer sought certiori from the United States Supreme Court, which the Supreme Court denied on October 13, 2015. Spinedex v. United, 770 F.3d 1282 (9th Cir. 2014), cert. denied, 136 S. Ct. 317 (2015).
Along with Cyr, was another landmark ERISA decision from the Ninth Circuit that Creitz & Serebin secured along with our co-counsel, Joe Garofolo. Here's a link to the Ninth Circuit's Decision. If you find yourself struggling with your ERISA plan's administrator or insurer over your benefits (pension, disability, health, or otherwise), let us see if we can help.
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