• Is Unum Denying More Disability Benefit Claims Than Usual?
  • Unum / Provident / Paul Revere Long & Short Term Disability Claims (Ep. 13)
  • Unum Disability Denial & Appeal Tips
  • Deposition of Insurance Co. Employee in a Disability Insurance Benefits Denial Lawsuit (Ep. 19)
  • Did Disability Insurance Claims Examiner Understand A Physician's Job Duties? (Ep. 22)
  • What relationship does UNUM have with hired doctors in disability insurance claims?
  • UNUM Lump Sum Settlement / Disability Lump Sum Buyout
  • 24 Month Self Reported Symptoms Limitation in Unum Disability Policy Case Study
  • Tips About a Unum Medical Examination in a Disability Benefit Claim

Disability insurance claimant’s allegation of bad faith against Unum Provident is disallowed due to ERISA regulations

A federal district court in California recently ruled that a disability claimant could not recover on his state-law claim for breach of implied covenant of good faith and fair dealing. This specific count is also known as “Bad Faith”. The court found that the disability plan at issue fell under the federal ERISA statute, and, as such, his state-law claim was preempted by ERISA. ERISA prohibits bad faith claims, which is why every insurer always wants a claim to be governed by ERISA. Check out our video on why ERISA is an unfair law. This case is a good summary of the law in California regarding when a disability policy may be exempt from ERISA. The California disability insurance attorneys that filed this ERISA disability lawsuit did a good job in trying to make this case exempt from ERISA. Let’s take a closer look to understand why the court found that the disability plan fell under the ERISA statute and why they ruled that his bad faith allegation was dismissed.

Ruben Gonzales worked as a sales team manager for Starwood Hotels and Resorts. During his employment with Starwood, Gonzales elected to participate in the Voluntary Workplace Disability Plan (the “VW Plan”). The VW Plan was a short-term disability plan that provided benefits in the amount of $5,000 per month for a maximum benefit period of six months. The Plan was issue by Provident.

Gonzales suffered a disability on June 8, 2007 following an operation for coronary artery disease. He applied for and was approved for benefits on August 6, 2007. However, in December of 2007, Provident stopped paying benefits under the VW plan. Gonzales’ first appeal was denied, and he never received a decision on his second appeal.

After not receiving word on his second appeal, Gonzales filed suit in the United States District Court of the Southern District of California. Gonzales filed two causes of action against Provident:

  1. a claim for benefits denied under the VW Plan; and
  2. a state-law claim for breach of the implied covenant of good faith and fair dealing.

Provident moved for summary judgment against the second claim.

Summary Judgment Standard

Summary judgment is a vehicle in which one of the parties can ask for a final judgment before a full trial is held. The party asking for summary judgment must demonstrate that there are no genuine issues of material fact requiring a trial, and they must also show that when you apply these undisputed facts to the law, their side is clearly entitled to a judgment.

Provident’s Argument

In its motion for summary judgment, Provident argued that the VW Plan qualifies as an employee welfare benefit plan, and as such, it falls under the regulatory regime of ERISA. Under ERISA, state-law claims for breach of the implied covenant of good faith and fair dealing are preempted if the claim is governed by ERISA.

In order for Provident’s argument to be successful, the Court must be convinced that the VW plan qualifies as an employee benefit plan in order to determine if ERISA applies.

The California Court’s Analysis

In order to determine whether the VW plan qualified as an employee benefit plan, the Federal Court first looked to the Act itself for the definition of an employee welfare benefit plan. The Act defines it as:

Any plan, fund, or program… established or maintained by an employer or employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, medical, surgical, or hospital care or benefits, or benefits in the events of sickness, accident, disability, death, or unemployment…

The Court noted that an employer can establish an ERISA plan rather easily. Establishing one requires nothing “more than arranging for a group-type insurance program. See, Credit Managers Ass’n of S. Cal v. Kennesaw Life & Accident Ins. Co. The Court observed that Starwood selected Provident’s short-term disability insurance coverage and made the plan available to its employees for supplemental coverage. Essentially, the court said, it arranged for a group-type insurance program, which, according to the Ninth Circuit in the Kennesaw Life case, is enough to establish a plan.

Although the Court was quick to determine that the VW Plan fell under what is considered an employee welfare benefit plan, the VW Plan may still be excluded from ERISA under the so-called “safe harbor” regulations. A plan will not be governed by ERISA if the plan meets all four elements of the safe harbor regulation. The safe harbor regulation provides that:

The terms ’employee welfare benefit plan’ and ‘welfare plan’ shall not include a group or group-type insurance program offered by an insurer to employees or members of an employee organization, under which:

  1. No contributions are made by an employer or employee organization;
  2. Participation in the program is completely voluntary for employees or members;
  3. The sole functions of the employer or employee organization with respect to the program are, without endorsing the program, to permit the insurer to publicize the program to employees or members, to collect premiums through payroll deductions or dues checkoffs and to remit them to the insurer; and
  4. The employer or employee organization receives no consideration in the form of cash or otherwise in connection with the program, other than reasonable compensation, excluding any profit, for administrative services actually rendered in connection with payroll deductions or dues checkoffs.

The parties agreed that the VW Plan satisfied each element of the safe harbor except one: the third element.

The third element, as mentioned above, requires a factual showing that the employer was substantially involved in the creation or administration of the plan. See, Thompson v. American Home Assur. Co. If an employer is more than a mere advertiser of group insurance, the plan is outside of the safe harbor provision. See, Kanne v. Conn. Gen. Life Ins. Co.

Here, Starwood did more than collect premiums and let Provident advertise. The facts showed that a vice president at Starwood worked with a manager at Provident to develop the benefit package for Starwood employees. Furthermore, Starwood and Provident held meetings to discuss the integration of the VW Plan with other disability programs. Starwood also gave input on the website for the VW Plan and on Provident’s call system for benefits. Finally, Starwood and Provident entered into a Performance Agreement which required both sides to meet certain targets regarding their handling of VW Plan Claims.

The Federal District Court for the Southern District of California found that Starwood’s involvement in the creation and implementation of the VW Plan, as well as the execution of the Performance Agreement was enough to not exempt the VW Plan from ERISA by the safe harbor regulation.

As state-law claims are completely preempted by ERISA, and because the VW Plan fell under ERISA, the Federal Court dismissed Gonzales’ claim for breach of the implied covenant of good faith and fair dealing. The Court also struck Gonzales’ demand for extra-contractual and punitive damages, as well as his request for a jury trial, as all are not available under ERISA. This case will continue with the one remaining count, which is the way most ERISA disability insurance cases are handled.

Collecting Unum Disability Benefits Is A Reality

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Questions About Hiring Us

Do you help Provident claimants nationwide?

We represent Provident clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Provident disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Provident. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Provident.

How do you help Provident claimants?

Our lawyers help individuals that have either purchased a Provident long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Provident:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Celestine D.

I am a 61 year old Senior Business Analyst. I had been working at a health insurance company for approximately 11 years when I became disabled and have had numerous, bulging disks, nerves that were severely impinged, and active arthritis and degenerative disk disease throughout my spine. I underwent back surgery for L1 thru L5 infusion which included insertion of 2 titanium rods and 6 pins. I continue to undergo physical therapy 3 xs per week. Not to mention the surgery left me worse than before the surgery considered a FAILED BACK SURGERY. I’m unable to sit or stand for more than 2 hours with getting up. I am unable to walk for more than 1 city block. I also have many other medical conditions. After collecting LTD from Lincoln Financial for about 3 years, the harassment began. They decided that I was no longer disabled. In short they felt I was capable of returning back to the work force. (Social Security Disability deemed me permanently disabled)

After fighting with Lincoln and exhausting my appeals I decided to research and hire an attorney. I selected Dell & Schaefer based on their website, case success statistics, and the speed at which they returned my calls and emails.

Let me tell you, my experience in working with Rachel Alters and her assistant Michal Mizrahi is nothing short of outstanding. They responded quickly to phone calls and emails and were mindful of my concerns and information needs. Talking with the both of them made me feel confident and assured they were doing the best for me. I cannot say enough good things about Michal. She anticipated my needs and was proactive in keeping me informed as my case progressed. What a TEAM they make. Any time I reached out with questions or concerns they were very responsive and always left me feeling satisfied that I had the best in my corner. Rachel is an angel. She is so down to earth compassionate, professional and trustworthy attorney. Rachel was there to guide me from the start and helped me get through this stressful and lengthy process.

While attempting to handle it on my own, my long-term-disability claim had been denied two previous times. With the help of Rachel Alters and her team, I was able to obtain a settlement I never would have been able to get without their assistance. Rachel and her team far exceeded my expectations in every capacity. She was focused, clear, responsive, efficient and above all exceedingly knowledgeable.

***** 5 stars based on 202 reviews

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