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On August 16, 2019 a nationwide class action lawsuit was filed in the U.S. District Court for the District of New Jersey against the medical device manufacturer Allergan to protect women with Allergan’s textured breast implants from the increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which has now been associated with Allergan’s BIOCELL textured breast implants. The case is Jane Doe I, et al. v. Allergan, Inc., et al., No. 2:19-cv-16784 (D.N.J.).

In July, The United States Food and Drug Administration (FDA) requested that Allergan issue a recall of its BIOCELL textured breast implants and tissue expanders, and Allergan agreed and is removing these products from the global market.

The FDA requested that Allergan recall all of its BIOCELL textured breast implants and tissue expanders based on newly submitted Medical Device Reports (MDRs) reporting worldwide cases of BIA-ALCL and BIA-ALCL-related deaths associated with these implants. The FDA’s “analysis was attributed to a new worldwide reported total of 573 unique BIA-ALCL cases including 33 patient deaths. Of the 573 cases of BIA-ALCL, 481 are reported to have Allergan breast implants at the time of diagnosis. In addition, 12 of 13 deaths occurring in patients with BIA-ALCL where the manufacturer was known occurred in patients implanted with an Allergan breast implant at the time of their BIA-ALCL diagnosis. The manufacturer and/or texture is unknown for the remaining 20 reported deaths from BIA-ALCL.”

Today the nation’s largest suicide prevention organization, the American Foundation for Suicide Prevention (“AFSP”), responded to the Federal Communications Commission’s (“FCC”) Report on the National Suicide Hotline Improvement Act to the U.S. Congress with this statement by John Madigan, AFSP Senior Vice President and Chief Public Policy Officer:

“We applaud the FCC, Substance Abuse and Mental Health Services Administration (SAMHSA), and Veterans Affairs (VA) for their work to analyze the effectiveness and the feasibility of a 3-digit hotline number. We agree with the initial conclusion of the FCC’s Report to Congress: that a universal, easy-to-remember, 3-digit phone number will make it easier to connect people in crisis with life-saving resources. AFSP is calling on the relevant congressional oversight committees of the Congress to continue their due diligence on this critical issue and immediately schedule a hearing to address the FCC’s recommendation to designate “988” as a new 3-digit number as there are significant questions and concerns which should be addressed, namely: Network Limitations – The North American Numbering Council’s Report to the FCC recognized that “988 likely cannot be deployed ubiquitously across all networks” in the United States and the FCC conceded that network upgrades and technology replacements will be necessary to “ultimately [make] the use of 988 as a designated suicide prevention and mental health crisis hotline ubiquitous” nationally.

The AFSP noted that, “It’s essential that a mental health and suicide prevention crisis number be nationally available for all individuals in crisis,” and they asked, “How will these gaps in national coverage be addressed so access is available regardless of geographic location?”

Due to their depth and breadth of knowledge, the attorneys at Kantor & Kantor are frequently asked to speak at seminars, conferences, or give presentations. In June of 2019, partner Brent Dorian Brehm was asked by a national continuing legal education (CLE) provider to speak about long term disability benefits.  The seminar was titled “Mastering Social Security, Long-term Disability & Government Benefits.” Mr. Brehm took the attendees on a journey from the start to the end of a long term disability claim – and everything in between. He also covered relevant differences between disability claims governed by state law and those governed by ERISA.

While we cannot provide you with the actual presentation or the question and answer segment that followed, we can provide Mr. Brehm’s outline. This information is valuable to anyone at any stage in the long term disability claim process. It starts from the beginning – explaining what LTD benefits are. It then goes through tips on making a successful LTD claim. It addresses what needs to be done during the claim stage to avoid litigation – but be ready for it if that must happen. And finally reviews the nuts and bolts of litigating both an ERISA and bad faith disability claim.

What are long term disability benefits?

Yahoo Finance published an article about how insurers try to prevent individuals from obtaining disability benefits. While the article discusses Canadian insurers, our experience is that the tactics described in that article also happen in the United States.

This blog elaborates on some of the points raised in the article, especially as they relate to ERISA insureds. The Yahoo article observed:

Surveillance is a common tactic. Insurers will hire private investigators to try to catch you in the act of doing something a disabled or injured person couldn’t, like moving a ladder or other heavy objects.

In an intensely litigated ESOP case involving 14 counts of ERISA violations, on April 22, 2019, Judge Staton, District Judge, Central District of California, certified a class of ESOP participants. The certification came after the court denied Defendants’ motions to dismiss all 14 counts. The case, as a whole, has many interesting legal issues, however, most interesting is the continued litigation of whether indemnification agreements for breaches of fiduciary duty are void.

As background, ERISA § 410 categorically voids indemnification agreements and states, in part “any provision in an agreement…which purports to relieve a fiduciary from responsibility or liability for any responsibility, obligation, or duty…shall be void as against public policy.” However, Department of Labor regulations have interpreted this to permit employer indemnification but not plan indemnification. (29 CFR 2509.75-4). The regulations also permit indemnification agreements so long as it does not relieve a fiduciary of responsibility or liability.

In 2009, we heard the first case in the 9th circuit that interpreted ERISA § 410 and its regulations, giving some clarity on the validity of indemnification agreements. In Johnson v. Couturier, 52 F.3d 1067 (9th Cir. July 27, 2009) the ESOP participants alleged defendants breached their fiduciary duties by allowing the company to pay excessive compensation to an officer who was a fiduciary to the plan. The company in Johnson was 100% ESOP owned and was in the process of liquidation. The indemnity agreement between officer-fiduciary and plan sponsor (company) provided indemnity unless due to gross negligence or deliberate wrongful acts. Despite the indemnity being paid from corporate assets, which would typically be permitted under DOL regulations, here, because the company was liquidating, the Court held that payment of indemnification by the company would reduce, dollar-for-dollar, the liquidating distribution from the plan – essentially paid by ESOP.

Disability is not measured only by one’s ability to lift, walk, stand, sit, etc.  Rather, the California definition of total disability in a policy insuring one’s ability to perform their own occupation is:

“A disability that renders one unable to perform with reasonable continuity the substantial and material acts necessary to pursue his usual occupation in the usual or customary way.”

In policies insuring one’s ability to perform “any occupation” or “any reasonable occupation,” the definition has been stated as:

In January of 2018, Judge Lawrence O’Neil issued a scathing ruling against Sun Life Financial, finding that it acted arbitrarily and capriciously when denying Ms. Vicki Young’s claim for ongoing disability benefits, and awarding said benefits to the Plaintiff, Ms.Young.

Ms. Young is a 62-year-old former mortgage broker who suffers from a severe form of fibromyalgia, and several other co-morbid conditions. After paying her LTD benefit for several years, Sun Life decided to terminate her benefit, arguing that the independent physician to whom Sun Life sent Ms. Young concluded that Ms. Young was able to return to a sedentary job, and that Ms. Young’s own physician agreed with that conclusion.

Judge O’Neil agreed with Kantor & Kantor’s argument – on Plaintiff’s Ms. Young’s behalf – that not only did Ms. Young’s treating physician support her disability claim (and was merely confused by an intentionally misleading form), Sun Life’s own independent physician actually gave restrictions and limitations which precluded Ms. Young from returning to applicable work under the terms of the policy.

When you think of what lawyers do for a living, the first thing you probably think of is arguing over a case in front of a judge.

You may be surprised to learn, then, that in the federal courts this staple of practicing law seems to be on the way out. The federal district courts – the trial courts of the federal system – are increasingly holding fewer and fewer oral arguments. Some district courts even have a standing default rule that they won’t hear oral argument on a motion unless the presiding judge explicitly asks for it.

This trend is even more accentuated in the federal circuit courts – the appellate courts of the federal system. While the Supreme Court of the United States holds oral argument in almost all of its cases, the circuit courts of appeal do not.

The classic “he said, she said” scenario shouldn’t apply to healthcare claims. A denial based on medical necessity arises when there are two opposing opinions: (1) the treating physician who recommends that a patient receive treatment necessary for the patient’s condition; and (2) the insurance company’s physician reviewer who has never seen the patient. In deciding medical necessity, the insurance company must consider clinical judgment. But whose clinical judgment applies?

Clinical judgment is defined as “the application of information based on actual observation of a patient combined with subjective and objective data that lead to a conclusion.” http://medical-dictionary.thefreedictionary.com/clinical+judgment.  In most cases, the only physician who has “actual observation of a patient” is the treating physician.

Yet insurance companies give little to no credence to the clinical judgment of treating physicians. For example, major health insurer, Anthem, states that its physician reviewers will apply guidelines, “Anthem corporate medical policy, and other decision-support material.” And when criteria is not available, “physician reviewers make a determination based on the available information and their independent clinical judgment.” https://www.anthem.com/wps/portal/ahpfooter?content_path=provider/nv/f4/s4/t0/pw_002053.htm&label=Medical%20Management

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