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The court is obliged to give deferred scrutiny to the ERISA claim



Employers who provided life insurance under the Employment Income Protection Act ("ERISA") usually require that the employee actually works for the employer before the employer, provided that the life insurance benefit enters into force. If you die before it comes into force, there is no policy and no coverage, regardless of the difficulty that is lacking on the recipient.

Pamela M. Morgan-Lapp v. Reliance Standard Life Insurance Co Civil Action No. 18-1085, US District Court of the Eastern District of Pennsylvania (February 14, 2019) Morgan-Lapp tried to force the court to cover after the insurer refused to give benefits because the deceased worker actually did not work before he died.

RELEVANT FACTUAL HISTORY

The parties filed an appeal for a summary judgment requesting that the court decide whether the plaintiff's husband, Mr Lapp, was covered by his employer, ERISA-controlled life insurance group ("Policy") when he died. About mr. Lapp was covered at the time he died, the plaintiff has the right to life insurance as a beneficiary.

Thomas Jefferson University hires Mr Lapp; Group Life Insurance Policy

On May 1

5, 2017, Thomas Jefferson University ("TJU") hired Mr Lapp. As an employee of TJU, Mr. Lapp can receive certain employment benefits, including life insurance within the framework of a group life insurance policy issued by the Defendant Reliance Standard Life Insurance Company.

Mr. Lapp's last day in the office; His hospital stay and death

On May 28, 2017, less than two weeks after TJU hired Mr. Lapp, he became ill and joined Kennedy Hospital in New Jersey. Mr Lapp remains at Kennedy Hospital and Thomas Jefferson Hospital until he died on July 13, 2017.

Owner Mrs Lapp surrenders a claim for death benefits under the policy. Defendant denies benefits; Defendant invokes decision on appeal

After mr. Lapp's death handed the case to Miss Lapp a claim for death benefits according to the policy. The defendant denied the plaintiff's claim. When denying the plaintiff's claim, the Defendant justified that Lapp was not covered by the policy when he died on July 13, 2017 because he was not "active at work" at any time after May 26, 2017, when Lapp was hospitalized. Because Lapp did not perform the material tasks at his job at the place where and in what way it would normally be carried out, Lapp was not active at work when he died and was therefore not a member of a qualified class

DISCUSSION

Brief Drug the conclusion that while Lapp may have fulfilled the requirements according to the policy, the policy did not enter into force on 1 June 2017 because Lapp was not active on the job as day or any day thereafter.

Mr. Lapp was not active at work on the day, and his coverage would begin. Therefore, Mr Lapp's coverage did not take effect

. The question of whether Mr Lapp did not report to the office at any time after his inauguration on May 28, 2017 made Lapp not "active at work" in connection with his right to benefits, the court concluded that the policy did not come into force for Mr Lapp when as preferably before his death because he was not only "active at work" – that is, he actually did work on the day he was covered was scheduled to start in place and way that such work is normally done – Mr. Lapp never returned to active work when any time before he died on July 13, 2017.

TJU hired Mr Lapp on May 15, 2017 as a qualified class 3 full-time employee TJU employee. When Mr Lapp was hired in mid-May, his policy coverage began on June 1, 2017, as "the first part of the month … next after the person becomes eligible" for benefits.

On June 1, 2017, the day when his life insurance cover was scheduled to begin, Lapp could not register for work, having become a hospital just a few days earlier. Also, evidence extrinsic to the administrative record presented by the applicant supports the conclusion that Mr Lapp was not active at work on 1 June 2017.

The Court rejected the plaintiff's arguments to the extent that it suggests that the term "active at work" as defined by the in the policy and as interpreted by the defendant – an ERISA plan administrator – is unreasonable because it is vague and ambiguous.

Having taken a position on the complainant's ERISA claims by confirming the defendant's administrative decision as reasonable, the court had no choice but to reject the plaintiff's allegation of breach of contract, as the claim was preceded.

It is evident that in cases involving erroneous denial of benefits under an ERISA plan, claims such as "breach of contract" and "breach of implied good faith and fair trade" as "refer to the unfair denial of benefits." under the plan "is" explicitly preceded. " Menkes v. Prudential Ins. Co., Am ., 762 F.3d 285, 296 (3d Cir. 2014).

In view of the mutual auditing standard that the Court is required to apply in this ERISA case, but not without distress over the unfortunate results – the defendant's interpretation of the policy is reasonable and that the defendant's decision to deny the plaintiff is some life insurance benefit for her husband death confirmed.

Federal Courts apply ERISA type-political disputes, because they apply disputes over National Flood Insurance Program policies, strictly. If the plan administrator does not violate the terms of the policy formulation or act incorrectly, the administrator's decision will be held. In this case, the court applied the clear language of the policy that Lapp was a hospital and died before the policy was established, and therefore his recipients are not entitled to recover.


© 2019 – Barry Zalma

This article, and all blog posts on this site, digest and summarize cases published by the courts of the various states and the United States. The court decisions have been modified from the actual language of the court decisions, condensed to facilitate reading and convey the author's views in each individual case.

Barry Zalma, Esq., CFE, now restricts his practice of service as an insurance consultant specializing in insurance coverage, insurance management, bad faith assurance, and insurance fraud nearly equal for insurers and policyholders. He also serves as an arbitrator or mediator for insurance-related disputes. He practiced law in California for more than 44 years as an insurance cover and law firm and more than 50 years in the insurance industry. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual liability magazine / ACE Legend Award.

Over the past 51 years, Barry Zalma has put his life on insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurers and their claims to become insurance managers.

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Read about this and other insurance books by Barry Zalma at http://zalma.com/blog/insurance-claims-library/

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