Illinois ERISA Lawyer Blog

Chicago area employees with coverage under an employer-sponsored life insurance or accidental death insurance plan have a reason to be concerned if they are genetically predisposed to or have higher risk of certain life threatening events occurring. The possibilities for exclusion of accidental deaths involving individuals suffering from illnesses like Alzheimer 's disease, Epilepsy, or the like could be endless. That is precisely what CIGNA--via its underwriting subsidiary, Life Insurance Company of North America--tried arguing in a recent accidental death insurance case.

In Ulyanenko v. Life Insurance Company of North America, No. 09-3513 (S.D.N.Y. Nov. 13, 2012), Nadia Ulyanenko ate a peach, and afterwards vomited and fell. She was taken to the hospital, where she suffered several seizures, and suffered cardiac arrest. The autopsy report stated Nadia died of a pulmonary embolism, caused by genetic mutations of certain heterozygotes, which made her 4-8 times more likely to experience such an event. CIGNA argued that Nadia's genetic predisposition constituted a sickness or disease within the meaning of the exclusion in the accidental death insurance policy. The court determined that a genetic predisposition is not a sickness, disease, or bodily infirmity that qualifies as a preexisting condition to exclude coverage. The court noted there is an important distinction between a disease, and a genetic predisposition to having a disease or suffering an event. The court stated it was not persuaded that a genetic predisposition, unknown throughout the decedent's life, could be a preexisting condition excluding coverage.

If your claim for accidental death benefits has been denied, call an experienced ERISA lawyer.

Long term disability applicants in Chicago are discovering that their employer sponsored long term disability insurance policies often have clauses which place a 24-month limit on disability benefits caused by any mental or psychiatric conditions, including depression, anxiety, ADHD, etc. For years, insurers would argue that a 24-month limitation applies any time a claimant's list of conditions included depression or anxiety. Claimants have been able to overcome those benefit terminations by showing that even if any mental or psychiatric conditions are ignored, they are nevertheless physically disabled. More recently, though, Prudential terminated benefits after a claimant developed severe cognitive impairments following a car accident in which he was injured. The court did not allow Prudential to get away with this one in White v. Prudential Insurance Co. of America, No. 11-3394 (E.D. Pa. Nov. 9, 2012).

After a 2007 auto accident, White was diagnosed with post-concussion syndrome--a traumatic brain injury--and experienced emotional and psychological strain, anxiety, and depression. Prudential denied White's initial claim, but after two appeals overturned the denial. After 24 months, Prudential terminated the payments, claiming the cognitive impairments were subject to the limit for mental illnesses. White appealed, but Prudential never responded to his appeal. White sent several letters following up with Prudential to try to spur a determination, but nothing happened. Almost a year later, White just filed his lawsuit. After White filed the lawsuit, Prudential produced a letter upholding the benefit denial. The letter was dated 10 months after White submitted the appeal, clearly in violation of ERISA's 45-day deadline for an insurer to respond to an appeal.

The judge awarded a judgment in White's favor. The judge determined that while ERISA does not require an insurer to give special weight to treating physicians' opinions over its own retained physicians' opinions, Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), Prudential improperly ignored all the opinions which concluded White's disability was caused by the head trauma suffered in the 2007 auto accident. Though the disability is due to a mental illness, if the mental illness is caused by a physical injury, then the 24-month limitation does not apply.

If your long term disability benefits have been terminated pursuant to a limitation on mental illnesses, and you believe the disability relates to a physical injury, call an experienced ERISA lawyer.

People around Chicago, and elsewhere in the country, have experienced a disturbing trend of employers telling them they have life insurance coverage, only to make a claim and have the insurer tell them the coverage lapsed, or they were not eligible insureds. The problem is that when people expect they have the coverage, they rely on it by having it be part of their planning for an unfortunate event. Often times the insurer is the responsible party, but occasionally it is the employer who sponsors the plan and buys the insurance. In a recent case, a court allowed a widow to proceed with claims against the employer for telling her late husband he had life insurance coverage, and even continuing to pay premiums for him during a period he was laid off.

In Teisman v. United of Omaha Life Insurance Co., No. 11-1211 (W.D. Mich. Nov. 8, 2012), the court held the widow had valid claims against her late husband's employer for breach of fiduciary duty and estoppel under the Employee Retirement Income Security Act ("ERISA"). When Jedco, Inc. laid off Mr. Tesman, it told him his life insurance would continue and that it would continue paying his premium. After he died, his widow made a claim to the insurer for the life insurance, but it denied the claim because Mr. Teisman was not eligible to be covered while he was laid off. She also raised claims against the employer, essentially seeking to hold it to its promise that Teisman had coverage. The court determined that in light of Cigna Corp. v. Amara, 131 S. Ct. 1866 (2011), the widow's claims for breach of fiduciary duty and estoppel against the employer could proceed. The claims have withstood summary judgment, meaning there may be a trial to resolve any issues of fact.

If you have experienced any kind of misrepresentation or misleading in a life insurance claim, it is critical to get the advice of a skilled ERISA lawyer. If you have questions about a life insurance claim, call an ERISA lawyer.

People in Chicago who are participants in an employer sponsored accidental death plan, and those who are named beneficiaries under such plan, should be concerned to discover the results of some cases involving accidental death in an auto accident where the decedent was under the influence of alcohol. Some policies have a specific exclusion for death where the insured person died while driving a car under the influence of alcohol. Despite such claims having been made now for decades, even where the policy lacks that specific exclusion, the insurers argue the death was not truly an "accident," essentially because of the risk of death from drunk driving.

Recently, Cigna--through one of its underwriting subsidiaries, Life Insurance Company of North America--scored another victory on such a case in Whinery v. Life Insurance Co. of North America, 10-9312 (C.D. Cal. Nov. 7, 2012). Mr. Whinery died in an automobile accident, wherein he had a blood alcohol content of 0.22, and was driving 90 mph down a city street. Cigna denied the claim because there was "no evidence to support that Mr. Whinery would not have been aware of the dangers directly associated with operating a vehicle while legally intoxicated." When Mr. Whinery's spouse sued, the court remanded to Cigna to determine whether the incident met the definition of "accident," namely whether it was unexpected or unintentional. Upon remand, Cigna denied the claim again.

The next time around in court documented Cigna had a practice of ignoring the actual definition of "accident," and instead evaluating "whether the conduct of the insured constitutes the significant assumption of an undue risk." The court stated this was a practice of utilizing incorrect policy definitions to deny claims involving intoxicated drivers. Nevertheless, given Mr. Whinery had three times the legal level of alcohol in his blood, and was driving 90 miles per hour, the court held Cigna did not abuse what little discretion it had. Though the death certificate listed the case of death as an accident, the court noted Mr. Whinery also had marijuana in his system, and a person who witnessed him driving stated "he's going to crash."

A case like this goes to show how important it is for a person claiming accidental death benefits to not merely rely on a death certificate that lists a cause of death. It is critical to get the help of an ERISA lawyer with experience in accidental death claims. If you have questions about accidental death insurance claim, call a knowledgeable ERISA lawyer.

Chicago area employees with employer-provided health insurance and individuals purchasing health insurance wonder what exactly will happen next with the Affordable Care Act, commonly referred to as "Obamacare." With a democrat-controlled Senate and White House at least through 2014, that means the most groundbreaking aspect of Obamacare--the individual mandate and prohibition on denial of coverage for preexisting conditions--will be implemented on January 1, 2014. This is when the health insurance exchanges are scheduled to be up and running. Implementation of Obamacare had two obstacles to overcome. It overcame the first after the Supreme Court decided in National Federation of Independent Business v. Sebelius that the individual mandate of the law is constitutional. The second obstacle to overcome was the 2012 general election. By November 16th, states must notify the federal government about how they intend to implement the health insurance exchanges. Many will open state-run exchanges. Others will either use a partnership-model with the federal government, or default to the federal exchange.

This is not to say health insurance will not continue to be without its difficulties. If you have been watching the news, you have undoubtedly heard about the looming "fiscal cliff." Medicare is scheduled to experience drastic cuts in reimbursement rates. And many highly anticipate there will be some sort of a "grand bargain" that would be a combination of trimming spending and increasing revenue. Currently, the exclusion from income of employer-sponsored health insurance is the single largest so-called "revenue loser" for the federal government, so don't be shocked to hear about proposals to limit that tax incentive, or eliminate it altogether.

If you have questions about how health care reform affects you, speak with a knowledgeable ERISA lawyer.