The decedent was a truck driver who was diagnosed with lung cancer in October 2013. Unfortunately, his cancer progressed, and in December 2014, it was discovered that it had metastasized to his brain. He stopped working for Reyes Holdings, LLC, that month in order to undergo extensive radiation and chemotherapy. He succumbed to his cancer in October 2016.
His wife applied for benefits under the life insurance policy he had obtained through his employer. Hartford denied her claim because at the time of his death he was no longer working for the company and thus was no longer an insured. No one in the human resources department at the business was able to help her, and she was ultimately referred to our office.
We obtained a copy of the policy and the claim file. Like most ERISA group life insurance policies, this one included a “waiver of premium if totally disabled” provision. We collected hundreds of pages of medical records and appealed the denial to Hartford. Even though the claim was technically “late,” (because no one had advised the decedent that he could actually extend his coverage beyond the last day he worked for Reyes Holdings, LLC,) Hartford agreed to pay the benefits.
Practice point: Understanding group life insurance policies and diving deep into the ERISA claim file and then making the correct argument is critical in these cases. In litigation, the standard of review in Federal Court will usually be “abuse of discretion.” Your appeal must contain all medical records, ERISA arguments and a “dissection” of the methodology that the insurance company used to deny the claim in order for the claim to be successful.Referral Fees Were Paid on this Claim