Life, Health & Disability
GRSM counsels and defends a large number of insurers in suits and arbitrations involving breach of contract and bad faith claims arising out of life, disability, health, and long term care insurance, as well as annuities, pension plans and retirement plans. During the past year, we have been victorious in several matters applying both abuse of discretion and de novo review to denials of disability claims. We have also reached numerous favorable settlements of benefits claims and high exposure breach of fiduciary duty claims. GRSM is proud to be named to “The Select List of Law Firms for the Defense in Life, Health & Disability Insurance” compiled by Res Loquitor Corporation. To qualify for the list, law firms are evaluated by at least five life and health insurance companies and the results must place a firm among the top one-third of all law firms. GRSM has been included in the prestigious list since 2007.
Representative matters include:
- Sales Practices Class Actions based on RICO and California Business & Professions Code § 17200, including extensive e-discovery relating to financial products including annuities
- Disputes arising out of alleged misrepresentation or fraud, including related remedies such as rescission
- Interpleader and related actions to resolve coverage issues, such as beneficiary disputes (including application of slayer statutes)
- Vicarious liability suits involving alleged broker-dealer or agent malpractice
- FINRA investigations and arbitrations
- Premium financing litigation
- Stranger-owned life insurance ("STOLI") disputes
- Regulatory disputes and related litigation, including Department of Insurance and Attorney General claims against insurers
- Financial elder abuse claims
- Incontestability disputes based upon concealment or fraud
- Life settlement claims
- Long term care insurance litigation
GRSM has a specialty practice group focused on ERISA disputes. The ERISA law team is part of our Insurance and Employment Practices groups, which have extensive experience handling disputes involving life, health, and disability insurance, including annuities, pension plans, retirement plans, and long term care insurance. Team Leader Ron Alberts published an article in the September 2009 issue of DRI Magazine, For The Defense, entitled "Circuits at Odds: A Year after Glenn - No Clear Path," which evaluates how each circuit court has interpreted the landmark ERISA decision of the United States Supreme Court, MetLife v. Glenn.
Our attorneys have comprehensive knowledge of ERISA substantive law and extensive experience litigating ERISA claims in the federal trial and appellate courts. Our ERISA experience involves not only claims for various employee benefits, but also complex breach of fiduciary duty claims against retirement and pension plan administrators. As ERISA litigation continues to increase, we have a team of experienced attorneys with substantial experience in the planning of ERISA litigation strategy and advising clients in the assessment of a wide range of risks. Our experience includes litigating claims in Arizona, California, Colorado, Nevada, Oregon, Texas, Washington, and Wyoming.
Our team recently represented a defendant health insurer in an ERISA action in federal court in which the plaintiff sought benefits for inpatient treatment he received for drug and alcohol abuse. The insurer denied coverage based on a finding that inpatient treatment was not the medically appropriate level of care. The U.S. District Court for the Central District of California ruled in favor of the insurance company. Shortly after the lawsuit was filed, a federal court granted a motion to dismiss for GRSM's client, a retirement plan, on a breach of fiduciary claim in a hybrid ERISA/wrongful termination lawsuit.
Examples of additional representative matters include:
- Breach of fiduciary duty claims against ERISA plan fiduciaries for alleged self dealing and violation of pension plan terms.
- Defense of suits seeking disability benefits under employer sponsored plans, both insured and self-insured.
- Disputes about the application of ERISA exemptions, e.g., government sponsored and church plans.
- Medical insurance claims seeking benefits denied as not medically necessary or experimental.
- Disputes over applicable plan regarding primary versus secondary status.
- Disputes about whether benefits plans comply with ERISA.
- Claims involving ERISA preemption against life insurer for agent's negligence in failing to establish IRS-compliant ESOP.
Health Care Plan Law
GRSM's Health Care Plan Law lawyers leverage the combination of specialty experience in health care contract litigation with extensive insurance coverage experience. We have resolved many contract claims brought by providers against payors, including insurers, HMOs, and self-insured plans.
We have handled claims ranging from benefit entitlement disputes and contract terms, to appropriate treatments and medical necessity determinations, to unbundling and usual and customary charges. The lawyers on our Health Care Plan Law team have a broad range of experience representing health care providers and health, life and disability insurance carriers in high profile litigation in state and federal courts throughout the U.S. Representative matters include:
- Claims for authorization and reimbursement of health benefits which are denied as experimental, investigational or not medically necessary.
- Fraudulent claims by health care providers seeking reimbursement for services either not rendered, not medically necessary, or in excess of usual and customary fees.
- Defense of claims by health care providers under contracts with payors, including insurers, health care service plans, and employers.
- Disputes among payors regarding applicable plan provisions and determining primary versus secondary payor.
- Disputes regarding application of stop-loss provisions, interpretation of maternity benefits, and proper case rates.