Joshua Bachrach (Partner-Philadelphia, PA) and Angela Heim (Of Counsel-Philadelphia, PA) represented a group long-term disability insurer in an appeal related to the denial of benefits. As a result of the plaintiff’s administrative appeal and before the lawsuit was filed, the client reversed the claim denial. The plaintiff still filed a lawsuit in the U.S. District Court, Western District of Oklahoma seeking attorney’s fees for the appeal. The plaintiff also challenged the client’s reduction of benefits under the policy based on her receipt of social security benefits, claiming financial hardship. The district court granted the defendant’s motion to dismiss the complaint for failure to state a claim, which was appealed to the Tenth Circuit. In a published decision, the Court of Appeals affirmed the judgment in our client’s favor. The Tenth Circuit joined seven other circuits in concluding that fees under ERISA’s fee-shifting statute are unavailable for pre-litigation proceedings. The court also rejected the plaintiff’s “backdoor route” seeking fees as equitable relief. As for the plaintiff’s claim related to the social security offset, the Tenth Circuit held that there was no need to consider the merits of it because she failed to exhaust her administrative remedies as courts have required under ERISA, the claim was time-barred, and the argument was waived because it was not pursued in the district court. Finally, the Court of Appeals rejected the claim that the plaintiff was entitled to equitable relief because our client failed to provide documents to her. Because she did not allege any separate harm related to this conduct, the court agreed with the district court that she was not entitled to any relief. The Tenth Circuit concluded its decision affirming the judgment of the district court by stating that “Plaintiff is receiving all the benefits to which her policy entitles her.”

Josh Bachrach (Partner-Philadelphia, PA) and Hannah Symonds (Of Counsel-Raleigh, NC) secured summary judgment for the firm’s carrier client in an ERISA long-term disability lawsuit in the United States District Court for the Eastern District of Missouri. The plaintiff, a truck driver, sought long-term disability benefits due to neck and back problems after claiming she was assaulted by a co-worker. The claim was denied based on the policy’s preexisting conditions limitation because the plaintiff was treated for neck and back problems within 12 months of her effective date of coverage. The court rejected the plaintiff’s argument that the treatment record relied upon in denying the claim was misdated. Under de novo review, the court concluded that the plaintiff was not entitled to benefits because she received treatment for chronic neck and back pain during the policy’s look-back period. Therefore, Josh and Hannah’s client was entitled to judgment in its favor. 

Joshua Bachrach (Partner-Philadelphia, PA) obtained summary judgment in favor of a claim administrator client in what the district court described as a “long-running dispute over disability coverage” under ERISA. The claims administrator concluded that the claimant was not totally disabled from any occupation after 24 months and discontinued benefits. After the ERISA lawsuit was filed, the court remanded the claim to our client regarding the applicability of a special conditions limitation rider. The plaintiff opposed the remand in multiple filings, arguing that the court should only consider whether she was disabled from any occupation because the rider was not initially raised. The court rejected the plaintiff’s argument and, after the claim was again denied based on the rider, it entered judgement in favor of our client. The court held that the rider applied to the claim “because Defendant cannot be required to provide benefits that are plainly excluded from the Policy’s coverage.” In response to the plaintiff’s equitable argument, the court responded that she produced no evidence that she was unaware of the rider at the time she applied for benefits. Also, “although the rider’s bar on long-term benefits has caused the plaintiff frustration and prolonged litigation, the defendant cannot be required to provide benefits that the plaintiff was never entitled to in the first place.”

Joshua Bachrach (Partner-Philadelphia, PA) and Angela Heim (Of Counsel-Philadelphia, PA) convinced the U.S. Court of Appeals for the Eleventh Circuit to reverse the judgment of the Southern District of Florida against our firm insurer client. The plaintiffs submitted a claim for $500,000 in accidental death benefits following the disappearance and presumed death of their father while mountain climbing in Pakistan. The district court concluded that because there was no evidence that the insured committed suicide, the denial of benefits was arbitrary and capricious under ERISA. In a published decision, the Eleventh Circuit reversed and remanded for entry of judgment in favor of our client. In doing so, the Eleventh Circuit adopted the Wickman test, which is used in seven other circuits for deciding whether a loss is an accident. Under this test, a court asks “whether a reasonable person, with background and characteristics similar to the insured, would have viewed [injury or death] as highly likely to occur as a result of the insured’s intentional conduct.” Here, the insured, a medical doctor, attempted to ascend a major peak solo after his climbing partner, a certified climbing instructor, concluded that it was too dangerous due to hidden crevasses and black ice that broke off and offered no grip. Based on these facts, the appellate court concluded that “[a] reasonable mountain climber likely would have expected a higher risk of injury or death from a summit attempt on an already dangerous winter climb.” The Eleventh Circuit rejected the claimants’ argument that the burden should shift to the insurer to prove there is no coverage when the actual cause of death is unknown. The appellate court also rejected the claimant’s argument that death while mountain climbing should be considered an accident because there is no mountain climbing exclusion in the policy. Accordingly, the Eleventh Circuit reversed the district court judgment and directed the district court to enter judgment in favor of our insurer client.

Joshua Bachrach (Partner-Philadelphia, PA) prevailed on a motion for summary judgment in an ERISA disability lawsuit seeking short- and long-term disability benefits. The district court agreed with our client, the insurer and claim administrator of the plans, that the plaintiff received benefits under the short-term disability plan for the maximum period allowed. Therefore, the court rejected the plaintiff’s argument that our client improperly transitioned his claim to the long-term disability plan to avoid further liability. Unlike the short-term disability plan, the long-term disability plan included an exclusion for preexisting conditions, which barred the claim. Therefore, Chief Judge John McConnel concluded that no short- or long-term disability benefits were owed and granted the motion for summary judgment in favor of the client.

Philadelphia partners Josh Bachrach and Heather Austin obtained summary judgment in favor of our carrier client in an ERISA case pending in federal court in Pennsylvania. The plaintiff previously worked as a registered nurse but stopped due to symptoms related to focal epilepsy. She described her symptoms as a déjà vu-like feeling that lasted for one to two minutes, followed be a few hours of fatigue and brain fog. Benefits were initially approved but denied after 24 months when the plaintiff had to prove that she was totally disabled from pursuing any occupation. The court rejected the plaintiff’s procedural challenges to the claim decision, including to the applicable standard of review in court. On the merits, the court concluded that our client reasonably rejected the opinions of the treating doctor, who overstated the number of episodes the plaintiff experienced each month and recommended testing to objectively confirm the claimed symptoms, but testing was never performed. The court also concluded that the alternative occupations identified by our client were reasonable. Therefore, the denial of additional benefits was not arbitrary and capricious and Josh and Heather proved our client was entitled to judgment in its favor. 

Heather Austin (Partner-Philadelphia, PA), Josh Bachrach (Partner-Philadelphia, PA) and Parks Stone (Partner-Atlanta, GA) obtained summary judgment in favor of our client carrier in an ERISA lawsuit pending in the U.S. District Court for the Northern District of Georgia. The plaintiff sought disability benefits shortly after she began working for the policyholder. But in the months before her coverage began, she was seen by doctors for fatigue, joint pain and swelling, muscle weakness, nausea, lung issues and stomach issues. A few months after she began working she was diagnosed with scleroderma and then stopped working. While scleroderma was responsible for all of the plaintiff’s symptoms, she argued that the policy’s preexisting conditions limitation did not apply to her claim because a diagnosis was not made until after she stopped working. Citing to an earlier Eleventh Circuit decision in which Wilson Elser represented the defendant, the court reached “the inescapable conclusion” that the client’s decision was reasonable and it was entitled to judgment in its favor.