Life, Health, and Disability Litigation

Overview

Robinson+Cole has successfully defended life, health, and disability claims brought in state or federal court against insurers, plan administrators, employers, and managed care organizations, including cases governed by the Employee Retirement Income Security Act (ERISA), the Federal Employees Health Benefits Act (FEHBA), Medicare, Medicaid, and the Federal Employees' Group Life Insurance (FEGLI) program. We also provide guidance, advice, and assistance to our clients regarding policies and procedures for managing life, health and disability claims.

The learning curve for this type of claim work can be steep. State insurance departments and federal regulators frequently change the rules and procedures governing coverage and claim evaluation, and it is necessary to know what has changed and why. Appellate courts, including the United States Supreme Court, regularly change the rules governing claim litigation. The language of insurance policies and benefit plans can sometimes be murky, requiring an experienced eye to comprehend them. And, it is often necessary to master a wide range of medical issues to fully understand, evaluate, and defend a claim. Our life, health, and disability litigation lawyers are able to maneuver the complexities of this environment. They know the framework inside and out and have worked on “building the law” in terms of life, health, and disability claims.

Our Services

Our lawyers have deep-seated experience in all areas of life, health, and disability litigation, including the following:

Health And Managed Care Litigation

  • trials of individual claims
  • federal appeals shaping ERISA procedures that govern insured benefit claims
  • complex health care issues involving ERISA, FEHBA, and Medicare preemption
  • payor/provider contract disputes
  • provider de-listing disputes
  • PBM antitrust claims
  • stop loss insurance disputes
  • nonparticipating provider reimbursement claims
  • pharmacy benefit plan/provider disputes
  • behavioral health claim disputes, including claims alleging violations of federal and state mental health parity and addiction equity laws

Disability Claim Litigation:

  • trials of individual claims
  • appeals
  • wrongful denial/termination of LTD benefits
  • interference with employee benefit rights
  • ERISA preemption
  • recoupment of overpaid benefits/subrogation
  • breach of fiduciary duty
  • bad faith
  • deceptive/unfair business practices

Life and Accident Claim Litigation

  • interpleader of life insurance benefits where there are conflicting claims for benefits
  • disputes over whether insured’s death was “accidental” or caused by self-inflicted injury
  • drug or alcohol intoxication
  • retained asset account litigation and disputes

Our wide spectrum of clients include the following:

  • insurance companies
  • life, health, disability, and accidental death and dismemberment (AD&D) benefit claim administrators
  • health maintenance organizations (HMOs)
  • preferred provider organizations (PPOs)
  • third-party administrators (TPA)
  • pharmacy benefit managers (PBMs)
  • chiropractic health care claim administrators
  • self-funded plan sponsors and administrators

In particular, we have represented claim administrators and plan sponsors in individual and class actions alleging breaches of ERISA fiduciary duty, violations of mental health parity laws, improper offsets against benefits for Social Security disability income benefits, and third-party tort settlements.

Our Team

Members of our team often present and write to national audiences about issues involving life, health, and disability matters. We also maintain the ERISA Claim Defense Blog at www.erisaclaimdefense.com. We are active members of these industry organizations:

  • the Defense Research Institute's (DRI) Life, Health, and Disability Committee
  • the ABA's Tort and Insurance Practice (TIPS) Committee on Life, Health, and Disability Insurance
  • the Association of Life Insurance Counsel (ALIC)
  • the International Association of Defense Counsel (IADC)
    • Experience
      • Health and Managed Care Litigation

      • Cicio v. Does, 385 F.3d 156 (2d Cir. 2004), on remand from U.S. Supreme Court (see Vytra Healthcare v. Cicio, 542 U.S. 933 (2004)) vacating Cicio v. Does, 321 F.3d 83 (2d Cir. 2003) and affirming Cicio v. Vytra Healthcare, 208 F. Supp. 2d 288 (E.D.N.Y 2001)—Plaintiff, on behalf of herself and her late husband's estate, brought a state court suit against an employee benefits plan administrator and others, asserting state law medical malpractice claims. Defendants removed action to federal court. The United States District Court for the Eastern District of New York denied plaintiff's motion to remand and dismissed action on ground that it was preempted by ERISA. Plaintiff appealed. Following partial affirmance, 321 F.3d 83, and remand, 542 U.S. 933, 124 S. Ct. 2902, 159 L.Ed.2d 808, the Court of Appeals held that claims were preempted by ERISA, affirming the District Court's ruling. This case was a companion case to Aetna Health Inc. v. Davila, in which the U.S. Supreme Court set forth a bright-line test for complete ERISA preemption. *

      • Obtained summary judgment for our clients, a self-funded medical plan for a major corporation and its claims administrator, in this ERISA matter in Florida federal court in which plaintiff alleged that the plan wrongfully denied her claim for behavioral health benefits. *

      • Obtained summary judgment for our client, a health insurance company, dismissing a claim for benefits under an ERISA-regulated health benefit plan seeking coverage for growth hormone replacement therapy (GHRT) for an adolescent on the grounds that the requested treatment was not medically necessary. *

      • Obtained dismissal with prejudice of a putative national class action on behalf of our client, a health plan, in a claim of wrongfully denied mental health care benefits filed in federal court. Plaintiff alleged that our client systematically and wrongfully denied in-patient mental health care benefits to plan beneficiaries who suffered from eating disorders. *

      • Disability Benefit Litigation

      • Advised one of country's largest disability insurers on modifying claim-handling policies and procedures to comply with new directives by the U.S. Department of Labor.

      • Successfully obtained dismissal of a disability claim due to the expiration of a contractual limitations period, and had that dismissal affirmed on appeal, in Heimeshoff v. Hartford Life & Accident Insurance Co. The U.S. Supreme Court affirmed the Second Circuit’s decision, resolving a conflict among Circuit Courts regarding the interplay between contractual limitations provisions required by most states’ insurance laws and federal case law regarding accrual of ERISA claims.

      • Represented clients in multiple jury trials in individual disability cases, including a claim by the principal of one of the country’s largest Social Security disability law firms based on deep vein thrombosis; a claim by an orthopedic surgeon/expert witness based on injuries in car accident; a claim by a practicing dentist based on fractured vertebra; a claim by a sales representative based on spinal injuries.

      • Represented multiple insurers in disability claims where disputes centered on the question of whether a disability was due to a mental illness or a physical cause, such as traumatic brain injury or "chronic" Lyme disease.

      • Represented disability insurer in multiple appeals and a remand regarding whether alleged delegation of authority to determine claims to an affiliate precluded arbitrary and capricious review of the claim.

      • Represented insurer in a successful appeal of a verdict awarding attorneys’ fees and future damages for breach of disability policy.

      • Obtained summary judgment for the insurer on appeal of defense that a disability policy was properly rescinded due to fraud by the insured in a policy application.

      • Defeated claim that a disability was not due to intentionally self-inflicted injuries where alleged aim of attempted suicide was death, not disabling injuries.

      • Ingravallo v. Hartford Life and Accident Insurance Company, as Administrator of the Delta Airlines Inc. Long-Term Disability Group Policy, 563 F. App’x 796 (2d Cir. 2014)—Obtained a favorable appellate ruling in the U.S. Court of Appeals for the Second Circuit reversing judgment for the plaintiff and entering judgment in favor of the defendant on the grounds that the District Court erred by finding that the defendant, the insurer/administrator of an ERISA regulated long-term disability benefit plan, acted arbitrarily and capriciously in denying plaintiff's claim for continuing disability benefits related to her multiple sclerosis diagnosis because her condition had improved and she no longer met the ERISA plan's definition of disabled. *

      • Patricia Burke v. PriceWaterhouseCoopers LLP Long Term Disability Plan and The Hartford Life and Accident Insurance Company, 572 F.3d 76 (2d Cir. 2009)—Addressing an issue of first impression for the circuit, the U.S. Circuit Court of Appeals for the Second Circuit affirmed the district court's ruling, upholding the explicit terms of a benefits plan's limitations period even though they required that the limitations period begin to run before the claimant could file a civil action under ERISA § 502(a)(1)(B). The Second Circuit ruled that the Department of Labor regulations allow ample time for plan participants to challenge an adverse decision and that the plan's terms must be enforced as written unless doing so prevented claimants from filing a timely lawsuit. This case was the basis for Heimeshoff v. Hartford Life Ins. Co., in which the U.S. Supreme Court held that ERISA plan limitation of actions provisions must be enforced as written, even if they begin the limitations period before the claimant can file a lawsuit to challenge the denial of a benefit claim. *

      • Thurber v. Aetna Life Insurance Company, 712 F.3d 654 (2d Cir. 2013) cert. denied 1345 Sup. Ct. 2723 (2014)—Obtained a favorable appellate ruling on two issues of first impression in the Second Circuit Court of Appeals in an ERISA-governed long-term disability claim for a benefits action on behalf of our client, a major insurer. In affirming the district court's grant of summary judgment to the insurer and reversing the district court on its denial of the insurer's counterclaim for return of overpaid plan benefits, the Second Circuit split with other circuits and made two precedential rulings favorable to ERISA plans. First, the Second Circuit ruled that the ERISA plan documents control as to whether the plan vests discretionary authority with a claim administrator, and ERISA does not require that the participant receive notice for the arbitrary and capricious standard of review to be applied by courts. Second, the Second Circuit ruled that recovery of overpayments of benefits caused by a plan participant's simultaneous receipt of "other income" benefits created an equitable lien by agreement, which permitted the insurer to seek return of the overpaid benefits under ERISA § 502(a)(3), even though the participant had dissipated the funds. In doing so, the Second Circuit reversed the district court's denial of the insurer's counterclaim under ERISA § 502(a)(3) to recover overpayment of short-term disability benefits. *

      • Life and AD&D Benefit Litigation

      • Assisted life insurer in resolution of benefit payment dispute involving a divorced ex-spouse and multiple children born to different mothers, with all children residing in Europe.

      • Represented AD&D insurer in a claim for accidental death benefits where the insured went missing off a boat on which he was sailing alone; the body was found weeks later, and the medical examiner was unable to determine cause of death.

      • Represented AD&D insurer in a claim for accidental death benefits following a single-car accident with no witnesses and the postmortem toxicology report showing intoxication.

      • Carol D. Faber v. Metropolitan Life Insurance Co., 648 F.3d 98 (2d Cir. 2011) — Obtained an affirmance from the U.S. Court of Appeals for the Second Circuit of the district court's order dismissing a putative class action against our client, which alleged that it had breached its fiduciary duties under ERISA by paying life insurance benefits through establishing and funding a retained asset and issuing beneficiaries checkbooks to access the fully funded account instead of issuing a lump sum settlement check. The Secretary of Labor filed a brief in which it essentially agreed with the defendant's argument that it had discharged its ERISA fiduciary duties once the beneficiaries' checkbook accounts were established. *

      • Obtained affirmance in the Second Circuit of a district court order granting summary judgment dismissing plaintiff's state law action alleging that she was entitled to $440,000 regarding her deceased husband's failure to convert his ERISA-based life insurance coverage to an individual life insurance policy on the grounds that the claim was completely preempted by ERISA. *

      • back to top

      * Atty. Michael Bernstein was counsel in these representative matters before joining Robinson+Cole.

Our Team

Members