Life, Health, Disability, and ERISA

Goldberg Segalla’s Global Insurance Services Practice Group has a nationally recognized team of insurance lawyers and litigators focused on life and health insurance, disability benefits, and Employee Retirement and Income Security Act (ERISA) matters. We serve the comprehensive needs of insurers, plan administrators, and others operating in the LHD and ERISA space.

Our team brings to each situation deep industry knowledge and proficiency navigating the nuances and complexities that characterize LHD and ERISA work. Our mastery of this area and our experience across the U.S. and international markets drive more practical counsel, more creative solutions, and stronger advocacy in coverage disputes. This is especially true in matters that cross jurisdictional lines, when understanding the interplay of varying rules and caselaw is critical to efficiency and success.

These are a few reasons why several of the world’s largest insurers trust us with their most complex, high-exposure LHD and ERISA matters.

A small sampling of the ways our team partners with clients follows.

Life Insurance

  • Claims involving questions whether a death was “accidental”
  • Contestability, fraud, and material misrepresentation (including foreign death schemes)
  • Lapsed or canceled policy issues
  • Beneficiary concerns and disputes, including those involving beneficiary changes and unique slayer statute scenarios
  • Policy rescission
  • Premium disputes and policy administration
  • Stranger-originated life insurance (STOLI) and corporate-owned life insurance (COLI)

Health Insurance

  • Disputes over payor submission deadlines and third-party billing
  • Health insurance and provider audits
  • Health Insurance Portability and Accountability Act (HIPAA) compliance and litigation
  • Health care subrogation and third-party lien disputes
  • Billing agent errors and omissions
  • Mandatory insurance reporting to Centers for Medicare and Medicaid Services (CMS)
  • Affordable Care Act compliance
  • Guidance regarding health insurance exchanges

Disability Benefits

  • Defeating challenges to discretionary clause language
  • Benefits limitation determinations, such as limits to an “own occupation” period as opposed to “any occupation”
  • Resolving disputes among overlapping disability policies
  • Litigation over plan conflicts of interest affecting the standard of review
  • Heightening efficiency by limiting discovery to the administrative record
  • Fraud investigations
  • Policy rescission

Employee Retirement and Income Security Act (ERISA)

  • Proactive and prompt removal of ERISA cases to the federal courts
  • Evolving issues concerning ERISA preemption, including preventing claims of estoppel, waiver, bad faith, fraud, etc.
  • Discretionary standards
  • Interference and retaliation claims under ERISA Section 510

Regulatory Guidance

  • Organization and licensing of life insurance companies
  • Guidance with life insurance and group disability insurance policy  form filings
  • Compliance with state insurance laws regarding corporate governance and disclosure rules
  • Compliance with New York Insurance Law requirements for first-year agent compensation
  • Filings submitted to demonstrate compliance with Section 4228 of the New York Insurance Law (agent compensation limitations)
  • Compliance with replacement rules for life and annuity contracts, including notifications and disclosures
  • Compliance with rules governing advertisement of life insurance and annuity contracts
  • Representation in market conduct examinations and agent disciplinary proceedings

Representative Matters

  • In a federal court action involving a long-term disability policy governed by ERISA, we successfully litigated the review of the insurer’s benefit decision under the plan. With benefits of $850,000 at stake, we efficiently and effectively minimized litigation costs by aggressively defending against discovery and proceeding to early dispositive motions seeking judgment on the administrative record. We successfully argued the motion and overcame allegations of a conflict of interest through the use of carefully crafted client affidavits. This litigation resulted in a lengthy reported decision that created positive precedent in the ERISA benefits field.
  • An ERISA insurer retained Goldberg Segalla to enforce its rights regarding an eligibility decision under an employee benefits plan. The case involved an intricate issue regarding interpretation of the plan’s terms surrounding “active work” and the effect of payments to a previous employee under a severance agreement. The federal district court upheld the insurer’s interpretation of the plan terms and cited wholesale from the brief prepared on behalf of our client. Additionally, we were successful in defending against the admission of extrinsic evidence outside of the administrative record.
  • In a case of first impression in New York, we used offensive interpleader to help a life insurer avoid impending litigation and rightfully prevent the vast majority of a $500,000 policy’s benefits from going to the mentally ill fiancé who murdered her. What made the case novel and complicated was the fact that a jury found the fiancé guilty but not criminally responsible for the policyholder’s murder — leaving the question of whether New York’s slayer statute, which had recently changed, applied. We convinced the court our client should be entitled for interpleader relief, and the court allowed the parties to negotiate an agreement amongst themselves. In addition, we guided the life insurer through establishment of a trust for the policyholder’s children, taking steps to minimize the risk of future litigation.
  • A health insurer called on our team to protect it from paying approximately $100,000 in medical treatment benefits to a serial fraudster. We acted for and guided the insurer through a number of legal and regulatory steps to counter the attempted fraud, including petitioning the state regulatory agency to give our client relief from the non-cancellable, guaranteed-renewable policy that had essentially handcuffed the insurer and the doctors from whom the policyholder repeatedly sought unnecessary treatment. We also filed notice to the state’s bankruptcy trustee to report the policyholder’s failure to disclose as income, when she filed for bankruptcy, the $35,000 in benefits she had already received from her fraudulent doctor visits.
  • Goldberg Segalla was regulatory counsel for a Japan-based life insurer in its $5 billion acquisition of a New York Stock Exchange-traded financial holding company and its nationwide U.S. insurance operations. Our role included contract drafting, regulatory due diligence, structuring corporate governance of the new combined insurance holding company group, and handling all regulatory approval applications, hearings and related activities, and preparation of enterprise risk-management reports.

Leaders in Life, Health, Disability, and ERISA Practice

Goldberg Segalla attorneys are nationally recognized leaders and authorities in the field of life, health, disability, and ERISA. Our team includes:

  • Author of the Second Circuit chapter in the American Bar Association’s ERISA Survey of Federal Circuits
  • An author of the “Life Insurance Claims Adjusting and Fraud” chapter in the LHD installment of Appleman on Insurance 3d, with an expanded section on stranger-originated life insurance (STOLI)
  • Frequent speakers and authors on issues related to discretionary language, insurance claw-backs in ERISA plans, and a broad range of life, health, disability, and ERISA topics