Our client's husband, a very popular youth coach, was diagnosed with leukemia in October 2014. At the time, he had an ERISA group life insurance policy through his job. Around the same time, his employer was in the process of switching insurance carriers and effective January 1, 2015, Lincoln National issued its life insurance policy.
He was receiving disability payments (due to his treatment, he had a low immune system so he could not be with the general public, and his work was classified so he could not work from home). The original insurance company offered all of the employees an opportunity to convert the group policy to an individual life and insurance policy and our client accepted.
Sadly, he passed away in October 2015, never having returned to work. After the original insurance company paid the individual life insurance claim, our client filed a claim with Lincoln, the new insurance carrier, under the group life policy. Lincoln denied the claim because the decedent had never returned to employment and been "actively at work" after January 1. Our client argued that the Lincoln National policy had been amended to cover employees like the decedent and that the decedent had met all of the conditions for coverage.
The case was litigated in the Eastern District of Virginia. The Judge ruled that Lincoln had abused its discretion in seeking to require our client to meet conditions other than the conditions set out in the policy amendment. Lincoln raised additional arguments in summary judgment, but those arguments were rejected because ERISA does not allow a defendant a claim to raise new matters in litigation.
Our client petitioned the court to order Lincoln to pay attorney fees under ERISA's fee-shifting mechanism. Lincoln agreed to settle that part of the claim and paid $35,000 of our client's attorney fees.