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Discretionary Clause in Boeing’s Long-term Disability Plan Found to Be Legal, Despite California Statute Banning Discretionary Clauses

California, one of the first states to ban discretionary clauses in disability insurance policies, is home to a recent decision by a federal court judge finding that the state statute banning discretionary clauses does not affect policies issued or renewed before January 1, 2012; and although the statute may void discretionary clauses in the insurance policy, it did not invalidate the discretionary clause in the Boeing Long-term Disability Plan.

California’s Statute Banning Discretionary Clauses

California Insurance Code Β§ 10110.6, effective January 1, 2012, states in relevant part:

(a) If a policy, contract, certificate, or agreement offered, issued, delivered, or renewed whether or not in California, that provides or funds life insurance or disability insurance coverage for any California resident contains a provision that reserves discretionary authority to the insurer, or an agent of the insurer, to determine eligibility for benefits or coverage, to interpret the terms of the policy, contract, certificate, or agreement, or to provide standards of interpretation or review that are inconsistent with the laws of this state, that provision is void and unenforceable…

Section 10110.6 Enactment of this statute means that the California legislature determined that it was unfair for an insurance company to give itself “discretion” – essentially give itself carte blanche authority to make any decision it wants without being susceptible to questioning or contradiction by a higher authority – since its financial stake in the claim creates a huge conflict of interest.

California’s Statute Banning Discretionary Clauses Does Not Apply To Disability Insurance Policies Issued Before January 1, 2012

Talana Orzechowski sued Aetna Life Insurance Company and her employer, Boeing Company’s, Long-Term Disability Plan, after Aetna, the disability plan’s Plan Administrator, terminated her disability benefits upon reaching the 24 month limitation for mental-nervous conditions. Ms. Orzechowski appealed Aetna’s termination claiming that she remained disabled from any gainful occupation due to physical conditions; however, Aetna refused to overturn its decision.

Ms. Orzechowski’s long-term disability lawyers disputed that Aetna’s decision should be given any deference because any grant of discretionary authority contained in the long-term disability plan was rendered void by California’s statute banning discretionary clauses.

The Court disagreed for two reasons. First, the Court determined that California’s statute did not apply retroactively, which in Ms. Orzechowsks case was prior to January 1, 2012. The Boeing Long-term Disability Plan was last renewed on January 1, 2011, a year before the statute became effective. The Court reasoned, “[e]ven if section 10110.6 applies to benefit plans that issue after the statute’s effective date, it has no application to preexisting benefit plans, such as the Plan here. Accordingly, the statute doesn’t render any provision of the Plan void.”

California’s Statute Banning Discretionary Clauses May Void Language in Disability Insurance Policy But Does Not Void Language in Boeing’s Plan Document

Second, the Court held that California’s anti-discretionary clause statute could possibly void the discretionary language in Aetna’s disability insurance policy document, but did not void the language in Boeing’s Plan Document, which is where Aetna’s discretionary authority originates from. Like many employers, Boeing maintained a Master Welfare Plan, an agreement to fund disability insurance coverage, and other welfare benefits, for its employees, as well as a Summary Plan Description, which communicated those benefits to the employees. Both documents contained discretionary clauses. The Court reasoned that since Ms. Orzechowski sued for denial of benefits under the Plan and was not suing for breach of the Aetna insurance policy, and because the insurer’s discretionary authority derived from the Plan, not the insurance policy, “[t]he Plan’s language unambiguously provides discretion to Aetna, and that language is not void by California law.”

Court Finds that Aetna Did Not Abuse It’s Discretion By Denying Ms. Orzechowski’s Claim For Long-term Disability Benefits

Following its finding that Aetna’s decision to deny Ms. Orzechowski’s long-term disability benefits should be afforded deference, the Court reviewed the merits of Ms. Orzechowski’s claim. Under the “deferential” abuse-of-discretion standard a plan administrator’s decision will not be disturbed if the plan administrator acted reasonably. This means that unless the judge finds that the administrator’s benefit decision was (1) illogical, (2) implausible, or (3) without support in inference that may be drawn from the facts in the record, then the judge must find in favor of the insurance company/plan administrator. Unfortunately for Ms. Orzechowski the Court found that Aetna’s decision to terminate her LTD benefits under the Plan’s mental-nervous limitation was reasonable, and disallowed recovery of benefits beyond the 24 months that she was paid.

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We represent Aetna 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 Aetna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Aetna. 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 Aetna.

How do you help Aetna claimants?

Our lawyers help individuals that have either purchased a Aetna 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 Aetna:

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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.

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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.

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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.

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My experience of dealing with The Hartford for my company LTD benefit was a nightmare from the start. Our company chose an “any occupation” clause from day 1 of disability leaving the door open to almost automatic decline. Of course, that is what happened.

I researched on the internet for days for a firm that knew ERISA Disability Laws and specialized in them. After an email to Dell & Schaefer, I received a call from an attorney named Victor the same day. After I described my occupation, he said “We have another attorney that I work with here who has helped many others in your occupation and I think he is better prepared than I to get you this benefit”. He about blew me away-sending business AWAY for MY sake? I knew, right then, that my choice of Dell & Schaefer was the correct one.

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