Published
This month’s Friday Five explores decisions (1) affirming the denial of accidental death benefits where a stroke substantially contributed to the insured’s fatal fall, (2) overturning the termination of a disabled attorney’s benefits because the administrator measured her against a generic lawyer rather than her legal specialty, (3) awarding a disabled surgeon more than $1 million after a bench trial on the administrator’s miscalculation of his monthly benefit, (4) permitting discovery beyond the administrative record on a separately pleaded breach of fiduciary duty claim, and (5) holding that an administrator’s failure to decide a disability appeal within ERISA’s 45-day deadline forfeits deferential review, and vacating the administrator’s denial of long-term disability benefits on de novo review.
The Saul Ewing ERISA Litigation Team
- Accidental Death Benefits Denied Where Stroke Substantially Contributed to Insured’s Fatal Fall. The U.S. District Court for the Middle District of Florida granted summary judgment to the defendant insurer, affirming its denial of accidental death and dismemberment benefits to the insured’s surviving spouse. The decedent suffered a stroke while standing in his home, fell, and struck his head on the floor. The autopsy listed the cause of death as a skull fracture with intracranial hemorrhage due to blunt impact, with the stroke (a cerebrovascular accident) as a contributory cause. The policy paid benefits only where the injury was the direct result of an accident and was “independent of illness.” Reviewing the denial de novo under the Eleventh Circuit’s framework, the court held that the plaintiff failed to carry her burden of establishing that the death was a direct result of an accident or independent of illness. Because the record showed the stroke caused the fall and was a contributory cause of death, Hartford’s denial was sustained. Additionally, the court held that the plaintiff abandoned her breach-of-fiduciary-duty claim by failing to raise it in her summary judgment briefing. Tegu-Watkins v. Hartford Life & Accident Ins. Co., No. 8:24-cv-2722-CEH-AAS, 2026 WL 2883359 (M.D. Fla. Sept. 25, 2026).
- Administrator Abused Its Discretion by Evaluating a Specialist Attorney Against the Generic Duties of a Lawyer. The U.S. District Court for the Eastern District of Pennsylvania granted summary judgment to a securities lawyer whose long-term disability benefits were terminated, ordering their retroactive reinstatement. The plaintiff, an Of Counsel attorney at a large law firm who specializes in securities law, received LTD benefits from September 2017 until the insurer terminated them in November 2023. A person is disabled under the plan if she is limited from performing the material and substantial duties of her “regular occupation.” For attorneys, the plan defined “regular occupation” as the attorney’s “specialty in the practice of law.” Instead of assessing whether the plaintiff could perform the material and substantial duties of a securities lawyer, the insurer had its vocational and medical reviewers measure the claimant against the general physical and cognitive demands of an attorney as performed in the national economy. Applying the arbitrary and capricious standard, the court held that the insurer’s reliance on generic attorney duties conflicted with the plain language of the plan and constituted an abuse of discretion. Because the insurer had improperly terminated benefits it previously approved, retroactive reinstatement was the appropriate remedy. Macpeak v. Unum Life Ins. Co. of Am., No. 24-1650, 2026 WL 2906206 (E.D. Pa. Sept. 28, 2026).
- Court Awards Disabled Surgeon Over $1 Million After Bench Trial on Benefit Miscalculation. Following a three-day bench trial, the U.S. District Court for the District of Maryland found that an insurer breached a group LTD policy by miscalculating a disabled orthopedic surgeon’s monthly benefit. The plaintiff, unable to perform surgery after two wrist operations, was insured under an “own occupation” policy, which provides a monthly disability benefits to replace a physician’s clinical income upon becoming disabled from their specialty, only to be reduced by the income they continued to derive from their medical specialty in spite of their disability. After approving plaintiff’s claim and issuing three payments, the insurer recalculated plaintiff’s claim and determined that he was no longer eligible for a monthly disability benefit. The court found this recalculation was incorrect under the terms of the policy: the insurer erroneously fixed the disability date in 2021 rather than 2022, used the wrong tax year for determining pre-disability earnings, improperly excluded the plaintiff’s corporate income from his pre-disability monthly earnings, and improperly counted non-clinical income as post-disability earnings – errors that together eliminated his monthly benefit. The court awarded $1,045,045.35 in actual damages plus prejudgment interest and granted declaratory relief. The plaintiff’s statutory bad faith claim failed as a matter of law, however, because the policy was a group rather than an individual policy. Grosso v. Unum Life Ins. Co. of Am., No. RDB-24-1432, 2026 WL 3120976 (D. Md. Oct. 16, 2026).
- Discovery Beyond the Administrative Record Permitted on a Separately Pleaded Fiduciary-Duty Claim. The U.S. District Court for the District of Minnesota overruled an administrator’s objections and affirmed a magistrate judge’s order allowing discovery outside the administrative record. Following the denial of his claim for LTD benefits, the plaintiff sued the insurer asserting a claim for benefits under 29 U.S.C. § 1132(a)(1)(B) and a claim for equitable relief under § 1132(a)(3) based on the insurer’s alleged breach-of-fiduciary duty in its claims handling. Plaintiff sought discovery outside of the administrative record regarding the insurer’s claims handling process; specifically, the plaintiff sought information about a conversation between his treating physician and the insurer’s physician reviewer, whether the insurer’s physician accurately reported that conversation, why the insurer continued to rely on the reviewer after plaintiff raised concerns about the account. The insurer argued that the fiduciary-duty claim was not meaningfully distinct from the benefits claim and that de novo review of the benefits claim rendered the claims-handling discovery irrelevant. Relying on Eighth Circuit precedent, the court held that a separately pleaded fiduciary-duty theory may turn on facts outside the administrative record, so permitting the discovery was neither clearly erroneous nor contrary to law. The order did not expand the record for the benefits claim, and the court held that Rule 26 continued to govern relevance and proportionality of the additional discovery. The court denied the plaintiff’s request for attorney’s fees because the insurer’s objections raised nonfrivolous questions. Gibson v. Unum Life Ins. Co. of Am., No. 25-2711 (JWB/JFD), 2026 WL 2983259 (D. Minn. Oct. 5, 2026).
- Late Appeal Decision Forfeits Deferential Review, and “Any Occupation” Denial Rejected on De Novo Review. The U.S. District Court for the Eastern District of Missouri granted summary judgment to a former nurse whose LTD benefits were terminated. The plaintiff became disabled after a hospitalization for diabetic ketoacidosis led to respiratory failure and the removal of part of her left lung. She qualified as disabled under the plan’s “Your Occupation” standard during the first 24 months, but the insurer found her not disabled under the higher “Any Occupation” standard that later took effect. However, because the insurer failed to decide her appeal within the 45 days required by ERISA regulations and the plan, the court held that the insurer “failed to exercise its fiduciary discretion,” and its decision was not entitled to deference. Reviewing the denial de novo, the court further held that the insurer’s decision contravened the plan and ERISA. In determining whether plaintiff could perform “Any Occupation” despite her disability, the insurer identified four occupations that all required her to undergo significant retraining in violation of the plan. Additionally, the court found that the insurer’s determination that the plaintiff could perform sedentary work ignored its own reviewing physician’s conclusion that she could only stand and walk about two hours per day – less than sedentary work requires. The court vacated the insurer’s termination of benefit and remanded for a renewed review. Farley v. Hartford Life & Accident Ins. Co., No. 4:24-cv-00894-SEP, 2026 WL 2971836 (E.D. Mo., Sept. 30, 2026).
Authors
