Monday, June 9, 2008

Play By The Rules Under ERISA or Else

Scalesred An unusually harsh employee benefits decision from the 9th Circuit? (via

A federal appellate court has turned away an appeal of an employee fighting for benefits under her employer’s disability plan because she did not play an active role in the disability determination process as mandated by the plan rules.

The 9th U.S. Circuit Court of Appeals ruled that Lumbermens Mutual Casualty Company was correct in denying benefits to plaintiff Linda Gertjejansen who had not attended the required case management conferences while her benefits request was being considered. The decision upheld a ruling by U.S. District Judge Virginia A. Phillips of the U.S. District Court for the Central District of California in favor of the insurer.

Gertjejansen was a nurse case manager handling workers compensation claims when she was involved in a June 2000 auto accident from which she suffered neck and back pain that she said eventually prohibited her from working. 

"It is clear from the record that Gertjejansen did not cooperate with repeated efforts to engage her in case management, making Lumbermens unable to reach a determination that Gertjejansen was disabled," the 9th Circuit panel wrote. "It is therefore irrelevant whether Gertjejansen was in fact disabled because her breach of the Plan's terms prevented such a determination from being made."

The decision might be right in this case, but does its reasoning not lend itself to abuse for future plan designs with arduous terms for employee participants?

The case is Gertjejansen v. Kemper Ins. Companies, Inc., 06-56329 (Apr. 28, 2008).


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