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Evaluating Benefits Determination Decisions For ERISA Conflicts Of Interest

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in Human Resources

Conflicts of interest in benefits decisions under the Employee Retirement Income Security Act (ERISA) have taken on a new life with extended risks for plan administrators. The Tenth Circuit recently established guidelines for plan administrators when a conflict exists between administering the plan and making benefits payment decisions.


Case Of Conflict

An employee was enrolled in her company's long-term disability plan in which the carrier was both the plan administrator and payor of claims. The carrier denied her claims for disability benefits because of a preexisting condition.


The employee appealed the benefit decision, supported by a formal request and letters from three doctors, but the carrier again denied the claim. She then sued the carrier for violating ERISA by denying her claim. A district court ruled that the carrier appropriately applied ERISA's "arbitrary and capricious standard of review"...(register to read more)

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