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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. MISSING
Regular Panel Decision
Mar 28, 2000

Oil Heat Institute of Long Island Insurance Trust v. Gerber Life Insurance

Plaintiff Oil Heat Institute of Long Island Insurance Trust (OHI) sued Gerber Life Insurance Company (Gerber), Island Group Administration, Inc. (IGA), and RMTS Associates, alleging Gerber refused to reimburse stop-loss claims and issue a letter of certification to a lender. OHI had established a self-insurance program, and Gerber issued an aggregate stop-loss (ASL) policy. OHI commenced the action on the day the ASL policy expired, before the attachment point for reimbursement could be calculated and before submitting proper documentation. The Supreme Court denied Gerber's motion for summary judgment. The Appellate Division reversed, finding that OHI failed to demonstrate compliance with the ASL policy's reimbursement terms, lacked material facts to support its claims, and initiated the action prematurely. Both causes of action were dismissed against Gerber.

Insurance LawSummary JudgmentAggregate Stop-Loss PolicyContract DisputeReimbursementPolicy TermsAppellate ReviewGood FaithDocumentation RequirementsAgency
References
3
Case No. MISSING
Regular Panel Decision

Medoy v. Warnaco Employees' Long Term Disability Insurance Plan

Plaintiff, Audrey Medoy, sued Warnaco Employees’ Long Term Disability Insurance Plan and Warnaco, Inc. (Defendants) under ERISA, alleging wrongful termination of disability benefits, failure to provide requested documents, and failure to retain claims records. Medoy's disability benefits were discontinued in 1987 without notice. After years of requesting information and appealing the decision, which was hampered by the destruction of her claims file, she filed this action in 1997. Defendants moved to dismiss the complaint, arguing that the claims were untimely, that Medoy was not a 'participant' entitled to disclosure, and that ERISA § 1027 did not cover claims records. The court denied Defendants' motion to dismiss on all grounds, finding her claims timely, her status as a 'participant' colorable, and claims records subject to retention under ERISA § 1027.

ERISALong-term Disability BenefitsStatute of LimitationsFailure to DiscloseRecord RetentionFutility ExceptionAccrual of ActionPlan Administrator DutiesParticipant StatusMotion to Dismiss
References
37
Case No. 12 Civ. 5645(KPF)
Regular Panel Decision
Feb 18, 2015

Wedge v. Shawmut Design & Construction Group Long Term Disability Insurance Plan

This case involves Plaintiff William Wedge's challenge under ERISA against the Shawmut Plan and Reliance Standard Life Insurance Company (RSLI) for the termination of his long-term disability benefits. Wedge, a former Senior Project Manager, suffered from Central Serous Chorioretinopathy (CSCR) and had his benefits denied by RSLI, which determined he was not "Totally Disabled" under the "Any Occupation" clause. The court applied an arbitrary and capricious standard of review, considering RSLI's structural conflict of interest but finding it warranted minimal weight. Ultimately, the court concluded that RSLI's decision, supported by comprehensive medical and vocational evidence, including an Independent Medical Examination, was reasonable and not arbitrary or capricious. Therefore, Plaintiff's motion for summary judgment was denied, and Defendants' motion was granted.

ERISA LitigationLong Term DisabilityBenefits DenialArbitrary and Capricious ReviewSummary Judgment MotionDiscretionary AuthorityConflict of InterestCentral Serous ChorioretinopathyMedical EvidenceVocational Assessment
References
46
Case No. MISSING
Regular Panel Decision

Wojciechowski v. Metropolitan Life Insurance

Plaintiff Paul J. Wojciechowski sued Metropolitan Life Insurance Company (Met Life) and IBM Corporation, his former employer, under the Employee Retirement Income Security Act of 1974 (ERISA), alleging wrongful denial of Long Term Disability (LTD) and Separation Pay benefits. Wojciechowski, an IBM employee since 1980, suffered back and spinal injuries from a 1993 car accident, leading to medical leaves and reports from his physician, Dr. Pani, indicating permanent disability. Met Life, the LTD plan administrator, denied his claim in 1997, a decision upheld on appeal. IBM also denied him severance pay, deeming his separation a voluntary resignation after his S&A leave expired and he failed to return to work. The court applied an arbitrary and capricious standard of review to Met Life's decision, finding it supported by substantial evidence and unaffected by a conflict of interest. Summary judgment was granted to IBM on the disability claims as it was not a fiduciary, and to both IBM and Met Life on all claims.

ERISALong Term Disability BenefitsSeverance PaySummary JudgmentArbitrary and Capricious StandardDe Novo ReviewFiduciary DutyPlan AdministratorConflict of InterestEmployee Benefits
References
26
Case No. MISSING
Regular Panel Decision

Maida v. Life Insurance Co. of North America

Plaintiff Anthony Maida sued Life Insurance Company of North America (LINA) after his long-term disability benefits were terminated. Maida initially claimed physical disability due to a fall and later asserted mental disability from post-traumatic stress disorder. The court granted LINA's motion for summary judgment on the physical disability claim, finding LINA's denial was not arbitrary and capricious based on multiple medical reports. Additionally, LINA was awarded $10,155 on its counterclaim for overpaid benefits. However, the court vacated LINA's rejection of the mental disability claim, deeming it arbitrary and capricious due to the lack of proper medical review, and remanded the matter to LINA for reconsideration, while retaining jurisdiction.

Disability BenefitsERISA LitigationSummary JudgmentArbitrary and Capricious ReviewRemand to AdministratorPost-Traumatic Stress DisorderPhysical Injury ClaimMental Health ClaimInsurance Policy DisputeOverpayment Reimbursement
References
19
Case No. MISSING
Regular Panel Decision

Polan v. STATE INS. DEPT.

Charlene Polan, suffering from a chronic psychiatric disability, challenged her insurer's 24-month limitation on long-term disability benefits for mental disorders, while physical disabilities were covered until age 65. She argued this violated Insurance Law § 4224 (b) (2), which prohibits insurers from limiting coverage solely due to disability without actuarial justification. After the New York State Insurance Department rejected her complaint, Polan initiated a CPLR article 78 proceeding. Both the Supreme Court and Appellate Division denied her petition, concluding that § 4224 (b) (2) does not mandate equal benefits for mental and physical disabilities. The Court of Appeals affirmed, interpreting the statute to prohibit discrimination against an individual based on their disability, not to require parity of benefits across different types of disabilities for all insureds.

DiscriminationDisability InsuranceMental DisabilityPhysical DisabilityInsurance LawStatutory InterpretationAntidiscrimination StatutesEmployee BenefitsLong-term DisabilityActuarial Principles
References
13
Case No. MISSING
Regular Panel Decision

Lauder v. First Unum Life Insurance

Plaintiff Barbara Lauder initiated an action against Coach Stores, Inc. and First Unum Life Insurance Company, alleging violations of ERISA and COBRA after her claim for long-term disability benefits was denied. Lauder contended she was entitled to benefits despite her employment termination and that Coach provided untimely notices. The court granted Coach's motion for summary judgment on claims three and four, ruling that Coach was not an ERISA fiduciary and COBRA does not cover long-term disability insurance. Lauder's motions for summary judgment on claims one and three were denied, and claim two against First Unum was dismissed for similar COBRA reasons, leaving a factual dispute regarding her employment status on one ERISA claim against First Unum.

ERISACOBRALong-Term Disability BenefitsSummary JudgmentFiduciary DutyEmployee Welfare Benefit PlanGroup Health PlanEmployment TerminationInsurance CoverageDenial of Benefits
References
21
Case No. 11 Civ. 804
Regular Panel Decision

China Media Express Holdings, Inc. ex rel. Barth v. Nexus Executive Risks, Ltd.

Plaintiff China MediaExpress Holdings, Inc., through its receiver, sued its insurers, American Home Assurance Company, China Pacific Insurance Co., and China Ping An Insurance (Hong Kong) Company Ltd., for breach of contract due to their refusal to defend and indemnify CME in underlying securities litigation. The defendant insurers moved to dismiss the complaint and compel arbitration in Hong Kong, citing arbitration clauses in their respective policies. The District Court granted the defendants' motions, finding the arbitration clauses to be broad and enforceable under the Federal Arbitration Act and the Convention on the Recognition and Enforcement of Foreign Arbitral Awards. The Court determined that all of CME's claims were subject to arbitration and, in accordance with Second Circuit precedent, stayed the proceedings pending arbitration in Hong Kong.

ArbitrationInternational ArbitrationFederal Arbitration ActConvention on the Recognition and Enforcement of Foreign Arbitral AwardsBreach of ContractInsurance Coverage DisputeSecurities LitigationStay of ProceedingsMotion to Compel ArbitrationReceiver
References
34
Case No. MISSING
Regular Panel Decision

Yuhas v. Provident Life & Casualty Insurance

Deborah Yuhas sued Provident Life and Casualty Insurance Company under ERISA for long-term disability benefits, claiming physical disability. Yuhas, a graphic designer, initially received benefits for a mental condition, which ceased after 24 months due to policy limitations. She subsequently appealed, claiming physical disabilities from a car accident, leading to a retroactive award of benefits for a specific period (October 1991 through May 1993) but no further benefits. Provident repeatedly denied her claim for benefits beyond May 1993, citing lack of objective physical disability and the expiration of appeal periods. Yuhas filed suit in September 2000, but the court granted Provident's motion for summary judgment, ruling that her claim was barred by the three-year statute of limitations, which had accrued by December 13, 1993, at the latest.

ERISALong Term Disability BenefitsSummary JudgmentStatute of LimitationsAccrual of Cause of ActionDisability Insurance PolicyMental DisorderPhysical InjuryAppeals ProcessRepudiation of Claim
References
13
Case No. MISSING
Regular Panel Decision

Bacquie v. Liberty Mutual Insurance Co.

Plaintiff Ena Mae Bacquie initiated an action under ERISA against her former employer, Liberty Mutual Insurance Company, and the sponsor of its Group Disability Income Policy, Liberty Life Assurance Company of Boston. She contested the defendants' decision to offset her long-term disability (LTD) benefits by the amount of her Social Security Disability Income (SSDI), primarily challenging the interpretation of "same Disability" in the context of multiple medical conditions. The court, applying an arbitrary and capricious standard of review due to the plan's discretionary authority granted to the administrator, found no evidence that Liberty's potential conflict of interest influenced its decision. Ultimately, the court upheld the defendants' interpretation, concluding that "Disability" refers to the inability to maintain employment rather than a specific diagnosis, and thus granted summary judgment to Liberty Mutual and Liberty Life Assurance Company of Boston, denying Bacquie's cross-motion.

ERISADisability BenefitsLTD BenefitsSSDI BenefitsBenefit OffsetSummary JudgmentPlan InterpretationArbitrary and Capricious StandardMedical ConditionsPsychiatric Disability
References
30
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