Ambiguity in an ERISA Plan Leads to $4 Million Court Ruling

January 28, 2020 | J. Price McNamara
Ambiguity in an ERISA Plan Leads to $4 Million Court Ruling Many employer-sponsored plans, including life insurance plans, are covered under the Employee Retirement Income Security Act, otherwise known as ERISA. It is important that you understand all of the policy language in your plan, as ambiguities in employer-sponsored ERISA plans sometimes exist.  In one recent case, a widow filed a lawsuit in a federal district court in Connecticut, alleging that the language in her insurance contract was ambiguous. The policy language in question stated that a life insurance plan beneficiary was entitled to benefits of “100 percent of a principal sum in the amount of five times [the worker’s] salary, subject to a minimum of $100,000 and a maximum of $1,000,000.” The deceased worker’s widow argued that the $100,000 and $1,000,000 limits applied to the bottom and top limits of the worker’s salary. In contrast, however, the employer argued that these limits applied to the top and bottom limits of the total amount to be paid the beneficiary. The court ultimately concluded that the contract language was ambiguous and that since there was more than one meaning that was reasonable, ordered the insurance company to pay the widow $4 million worth of additional benefits.  Unfortunately, in some instances, the terms of ERISA plan documents are ambiguous to the detriment of the insured individual. If you feel that you have wrongfully been denied benefits under your employer-sponsored ERISA plan, it is important that you obtain experienced legal counsel as soon as possible. The knowledgeable Louisiana ERISA lawyers at J. Price McNamara ERISA Insurance Claim Attorney can make sure that you understand your plan’s language and could appeal a wrongful denial of benefits under your plan. 

Reasons for a Claim Denial

There are many different reasons why an insurance company might deny your claim for benefits under an employer-sponsored plan. For example, the insurance company might contend that you failed to make one or more premium payments or that the statistics which you provided in the insurance policy (e.g., regarding medical conditions, age, health, etc.) differ from the facts. Finally, the insurance company might contend that you suffer from a preexisting medical condition that excludes you from coverage. 

What Happens when the Contract Language is Ambiguous?

When contract language in an insurance policy is ambiguous, with regard to ERISA disability insurance cases, the ambiguous language must generally be construed in favor of the insured and against the insurer. In other words, the insured’s “reasonable expectations” usually govern when it comes to ambiguous language in an insurance policy.  If you have wrongfully been denied coverage under an ERISA plan, an experienced Louisiana ERISA lawyer can review your claim and could help you file an administrative appeal with your insurance company. 

Contact a Louisiana ERISA Lawyer Today

Ambiguous contract language in an ERISA plan sometimes favors the insured. Let the experienced legal team at J. Price McNamara ERISA Insurance Claim Attorney assist you with pursuing the benefits that you deserve under your employer-sponsored ERISA plan, in the event of a dispute. To schedule a free legal consultation and case evaluation with a Louisiana ERISA attorney, please contact us online today for more information. 
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J. Price McNamara

Attorney

Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!

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