Our Wins

Kantor & Kantor represented a beneficiary whose ERISA-governed life insurance claim was denied after the insured’s death, leaving the family without benefits intended to replace income and provide financial stability following the loss. While the insurance appeal was pending, the beneficiary entered into an employment separation agreement after being advised that the insurer was a separate entity and that the agreement would not affect the pending benefits claim.

After the appeal proceeded, Sun Life asserted for the first time that the employment release barred the ERISA claim against the insurer. Sun Life relied on broad release language directed at the employer and attempted to extend it to the insurer, despite the absence of any express waiver of life insurance benefits and despite representations made to the claimant at the time of separation.

The Second Circuit rejected Sun Life’s attempt to use an employment agreement to avoid paying life insurance benefits. The court held that waivers of ERISA rights must be knowing, explicit, and informed, and it foreclosed insurers from piggybacking on employer releases to extinguish independent benefit obligations.

This case arose from UnitedHealthcare’s denial of continued residential treatment for a minor diagnosed with severe anorexia nervosa, a condition carrying significant medical risk. Treating physicians documented ongoing medical instability, insufficient weight restoration, and a high likelihood of relapse without continued structured inpatient care.

UnitedHealthcare initially approved a higher level of care but later downgraded coverage and denied continued residential treatment. The insurer relied on utilization review opinions that conflicted with treating-provider assessments and discounted longitudinal treatment records documenting relapse risk and medical necessity.

The Fifth Circuit held that UnitedHealthcare failed to meaningfully engage with the medical evidence submitted in support of the claim. The decision reinforced that ERISA insurers may not justify denials by selectively citing favorable facts while ignoring treating-provider warnings about serious health risks.

Kantor & Kantor represented a widow seeking accidental death benefits after her husband died from a heroin overdose. Symetra denied the claim under an ERISA-governed life insurance policy, cutting off benefits sought following the death.

Rather than addressing the merits of the accidental death claim, Symetra asserted that the beneficiary failed to exhaust administrative remedies. The insurer relied on exhaustion even though the plan documents did not clearly identify or explain any appeal process applicable to accidental death claims.

The Eighth Circuit rejected Symetra’s exhaustion defense and held that insurers may not rely on undisclosed or opaque review procedures to bar beneficiaries from court. The ruling strengthened procedural protections for life insurance claimants and forced insurers to clearly disclose appeal rights before invoking exhaustion.

This case involved a claim for accidental death benefits following a fatal motor vehicle accident. LINA denied benefits, asserting that the death was not accidental due to alleged foreseeability and risk-taking conduct.

During litigation, LINA attempted to defend the denial using arguments and theories that were not raised during the administrative claims process. Kantor & Kantor challenged the insurer’s effort to reshape its rationale after the fact.

The Ninth Circuit barred LINA from introducing new justifications on appeal and emphasized that ERISA benefit determinations must stand or fall based on the reasons given at the time of denial. The decision curtailed insurers’ ability to retrofit defenses once litigation begins.

The claimant sought ERISA life insurance benefits after Lincoln Life denied a claim following a death. The denial left the beneficiary without payment under a policy intended to provide post-loss financial protection.

In litigation, Lincoln Life attempted to defend its decision using explanations that were not fully articulated in the administrative denial. Kantor & Kantor argued that the insurer was improperly supplementing the record with post-hoc rationales.

The Ninth Circuit held that ERISA review is limited to the reasons actually stated during the claims process and rejected Lincoln Life’s attempt to rely on new explanations. The ruling reinforced that insurers must fully and honestly explain their denials at the administrative stage.

Kantor & Kantor represented a claimant seeking long-term disability benefits based on significant physical impairments that prevented sustained work activity. Treating physicians documented functional limitations affecting the claimant’s ability to stand, walk, and remain physically active for a full workday, rendering consistent employment impossible.

Reliance Standard denied benefits by elevating non-examining file reviewers over treating providers and minimizing clinical findings supporting disability. The insurer framed the dispute as a neutral difference of medical opinion while giving decisive weight to paper reviews that downplayed the claimant’s functional limitations and ignored the longitudinal medical record.

The Fourth Circuit rejected Reliance Standard’s approach and held that courts are not required to defer to insurer-retained reviewers. The decision confirmed that judges may meaningfully weigh competing medical evidence rather than rubber-stamping insurer file reviews, reshaping how disability claims are evaluated throughout the circuit and nationally.

The claimant, an executive sous-chef, sought long-term disability benefits due to chronic osteomyelitis, degenerative disc disease, and spinal stenosis. His conditions caused persistent pain, limited mobility, and an inability to stand or walk for prolonged periods—core physical demands of his occupation in a commercial kitchen environment.

Hartford initially approved benefits, then terminated them after relying on non-examining physicians who discounted treating-provider opinions and objective findings. The termination occurred despite continued medical evidence showing no meaningful improvement and ongoing restrictions incompatible with the claimant’s job duties.

The Fourth Circuit reversed and directed entry of judgment for the claimant. The court rejected Hartford’s selective review of the record and reinforced that insurers may not terminate established disability benefits without honestly confronting the medical evidence supporting continued impairment.

Kantor & Kantor represented a claimant whose long-term disability benefits were denied under a Boeing-sponsored ERISA plan administered by Aetna. The denial placed the claimant’s income and financial stability at risk despite prior approval of benefits.

The plan defended the denial under a deferential standard of review based on discretionary language embedded in the policy. Kantor & Kantor challenged whether that discretionary clause was enforceable under California law.

The Ninth Circuit held that California Insurance Code § 10110.6 voided the plan’s discretionary clause and required de novo review of the denial. The ruling stripped insurers of deferential review in covered policies and materially changed how disability claims are litigated across California.

The claimant sought coverage for partial hospitalization and residential mental health treatment after outpatient care proved insufficient to manage serious psychiatric symptoms. Treating providers determined a higher level of care was medically necessary to stabilize the condition and prevent deterioration.

Humana curtailed coverage by applying restrictive medical-necessity standards to mental health treatment that were not applied to comparable medical or surgical care. Kantor & Kantor challenged both the denial itself and the standard of review governing ERISA benefit determinations in the Fifth Circuit.

Sitting en banc, the Fifth Circuit overruled prior precedent, clarified the default ERISA standard of review, and addressed parity principles governing mental health coverage. The decision reshaped ERISA litigation in the circuit and strengthened enforcement of federal mental health parity protections.

The claimant was diagnosed with anorexia nervosa and required residential mental health treatment after outpatient and partial hospitalization care proved inadequate. Blue Shield denied coverage while continuing to cover analogous inpatient medical services.

Blue Shield relied on plan exclusions to deny residential mental health treatment despite medical necessity and despite parity protections under California law. Kantor & Kantor challenged the denial under ERISA and the state Mental Health Parity Act.

The Ninth Circuit held that medically necessary residential mental health treatment must be covered when comparable medical treatment is covered. The decision became a cornerstone of mental health parity litigation and forced insurers to cover higher-level mental health care they had routinely denied.

The claimant sought coverage for residential mental health treatment after being diagnosed with anorexia nervosa. Her treating physicians determined that outpatient and partial hospitalization care had failed and that residential treatment was medically necessary to address the severity of her condition.

Blue Shield denied coverage and issued a denial letter that relied on specific policy grounds to justify refusing payment. After litigation began, however, Blue Shield attempted to defend the denial by advancing new reasons and policy interpretations that had not been raised during the administrative claims process.

The Ninth Circuit held that an ERISA insurer may not defend a benefits denial using rationales that were not articulated during the administrative process. The court rejected Blue Shield’s attempt to introduce new arguments in litigation and confined judicial review to the reasons actually given to the claimant. The ruling forced insurers to fully and accurately state all grounds for denial up front and eliminated the ability to “save” a deficient denial by inventing new defenses after suit is filed.

Kathy Dine received long-term disability benefits under an ERISA-governed plan after medical conditions rendered her unable to continue working. Her treating physicians continued to document functional limitations that interfered with sustained, full-time employment.

MetLife terminated benefits, asserting that Dine no longer met the plan’s disability definition. MetLife both evaluated claims and paid benefits under the plan, creating a structural conflict of interest. Kantor & Kantor challenged the termination as unsupported by the medical record and tainted by the insurer’s financial conflict.

The Ninth Circuit reversed the termination and remanded the case. On remand, the district court entered judgment reinstating benefits. The outcome reinforced that conflicted administrators must justify terminations with record-based reasoning and that courts will scrutinize termination decisions where insurers act as both judge and payor.

Judi Peterson sought long-term disability benefits based on chronic fatigue syndrome, reporting persistent exhaustion, cognitive impairment, and inability to sustain reliable attendance or productivity in a competitive work environment. Treating providers documented limitations inconsistent with full-time employment.

AT&T terminated benefits and defended the decision under a discretionary standard of review, asserting that the evidence failed to support ongoing disability. Kantor & Kantor challenged the termination as a selective evaluation of the record that minimized functional impact in favor of insurer-chosen interpretations.

The court found that AT&T abused its discretion by failing to fairly evaluate the medical evidence and by discounting the real-world functional limitations caused by chronic fatigue syndrome. The ruling reversed the termination and reinforced protections for claimants with conditions that do not lend themselves to simple objective testing.

Andre LeGras sought continued disability benefits and pursued an administrative appeal after receiving a denial. The appeal deadline fell on a weekend, and Aetna treated the appeal as untimely, asserting that the missed deadline barred judicial review of the claim.

Kantor & Kantor challenged Aetna’s rigid deadline interpretation and argued that ERISA exhaustion requirements are governed by federal common law, not hyper-technical timing rules designed to shut claimants out of court.

The Ninth Circuit held that when an appeal deadline falls on a weekend, the deadline extends to the next business day. The decision reversed dismissal of the claim and prevented insurers from using technical deadline traps to avoid judicial review of benefit denials.

Donald Kurth, M.D., sought disability benefits after medical conditions impaired his ability to safely and consistently practice medicine. Treating providers documented limitations affecting endurance, cognitive functioning, and the ability to perform complex professional tasks required of a physician.

Hartford denied the claim based exclusively on file reviews conducted by non-examining physicians and declined to obtain an independent medical examination. The insurer discounted treating-provider opinions and framed the evidence as insufficient to establish disability.

After trial, the court scrutinized Hartford’s claims-handling process and its failure to meaningfully engage with the treating medical evidence. The decision highlighted the risks insurers face when denying professional disability claims without examining the claimant or grappling with treating-provider assessments.

Michael Mitchell stopped working after developing chronic fatigue syndrome, restless legs syndrome, hemochromatosis, and major depressive disorder. Treating physicians documented profound fatigue, sleep disruption, cognitive impairment, and reduced stamina that prevented sustained work activity.

MetLife denied long-term disability benefits by relying on non-examining file reviewers who discounted treating-provider assessments and emphasized the lack of objective laboratory findings to quantify fatigue and sleep disturbance. The insurer minimized the cumulative effect of multiple conditions.

After a bench-style adjudication on the administrative record, the court found MetLife’s denial unsupported by the evidence, credited the treating physicians’ assessments, and awarded long-term disability benefits. The ruling reinforced that disability determinations must focus on functional impact, not the absence of easily measurable objective markers.

Dennis Wible, acting as trustee for the estate of Marianne Wible, sought ERISA disability and life insurance benefits after Ms. Wible became unable to work due to systemic lupus erythematosus and related autoimmune complications. Medical records documented severe fatigue, joint pain, systemic involvement, and fluctuating symptoms characteristic of lupus, which impaired her ability to maintain regular employment.

Aetna denied benefits and disputed the severity and functional impact of Ms. Wible’s condition. The insurer relied on selective readings of the medical record and asserted that its decision was entitled to deferential review under discretionary plan language, seeking to limit the scope of judicial review.

The court rejected Aetna’s attempt to control the standard of review and held that de novo review applied. The ruling resolved a threshold issue that governed how the claim would be evaluated and ensured the court could independently assess the medical evidence supporting disability and benefit entitlement.

Cheryl Bowen alleged that prolonged exposure to toxic mold and bacteria in her workplace caused the recurrence of systemic lupus erythematosus that had previously been in remission and triggered severe asthma and allergic disease. Her condition resulted in repeated episodes of anaphylactic shock, emergency treatment, and frequent hospitalizations, sometimes occurring every four to six weeks.

Treating physicians prescribed daily intravenous Benadryl and Phenergan, administered through a surgically implanted port-a-cath, which dramatically reduced hospitalizations and steroid dependence. After a change in plan administration, the plan approved the port insertion but denied coverage for the prescribed IV medications as not medically necessary, relying on non-examining reviewers despite the life-threatening consequences of interrupted treatment.

Bowen sought injunctive relief under ERISA to prevent termination of prescribed care during litigation. The court conducted a detailed review of the medical record and claims-handling process and addressed whether ERISA permits an insurer to withhold physician-prescribed, life-sustaining treatment while a benefits dispute is pending.

The claimant sought continued inpatient psychiatric treatment for major depressive disorder (recurrent), dissociative identity disorder, post-traumatic stress disorder, and bulimia. Treating psychiatrists documented dissociative episodes, eating-disorder behaviors, and a high risk of decompensation without structured inpatient care.

The insurer initially approved inpatient treatment from May 11, 2004 through August 29, 2004, then denied further coverage, asserting the claimant could transition to outpatient care based on selective symptom improvement. The denial discounted treating-provider assessments documenting ongoing instability and relapse risk.

Applying California’s Mental Health Parity Act and conducting de novo review, the court held that the claimant was entitled to continued inpatient benefits. The decision limited insurers’ ability to downgrade care for serious mental health conditions while continuing to cover comparable medical treatment.

Willow Rorabaugh worked as a Branch Office Administrator, a position requiring sustained sitting, frequent hand use, bending, twisting, and postural tolerance. She underwent back surgery for spinal stenosis in April 2003 and initially received short-term disability benefits.

Her recovery was complicated by progressive neurological symptoms, including gait disturbance, rigidity, fatigue, and tremors. Neurology evaluations resulted in a Parkinson’s disease diagnosis. Treating physicians concluded she could not return to work. The insurer relied on internal duration guidelines and generalized “sedentary work” assumptions rather than evaluating her actual occupational duties and failed to properly transition the claim to long-term disability.

After a bench trial under de novo review, the district court found Rorabaugh totally disabled under the plan and awarded benefits. The Ninth Circuit affirmed, rejecting disability determinations based on abstract sedentary-work concepts divorced from real job demands.

Stacey Shane began receiving long-term disability benefits after a knee injury prevented her from continuing her job duties. Benefits were approved and paid for an extended period under the plan in effect at the time her disability began.

After a later recertification process, Albertson’s terminated benefits and denied her appeal. The plan argued that later amendments applied retroactively and that discretionary authority supported the termination.

The Ninth Circuit held that the earlier plan governed because it expressly limited amendments to future disabilities. The ruling prevented retroactive application of more restrictive standards and clarified how plan amendments and discretionary authority operate under ERISA.

Welch filed suit challenging MetLife’s denial of long-term disability benefits. Approximately six months after litigation began, MetLife paid the claim in full, converting the case into a dispute over attorney’s fees incurred to obtain payment.

The district court substantially reduced the fee award, lowering hourly rates and imposing across-the-board reductions based on billing practices.

The Ninth Circuit held that portions of the reduction were improper, rejected artificially low hourly rates, and remanded for recalculation. The decision affected how attorney’s fees are evaluated when insurers pay valid claims only after litigation forces the issue.

Ioane John Opeta sought a disability pension based on total and permanent disability after medical conditions forced him to stop working. The pension plan denied benefits, asserting that Opeta did not meet the plan’s disability definition.

Kantor & Kantor challenged how the plan interpreted and applied its disability standard, including how medical evidence must be evaluated under ERISA pension provisions.

The Ninth Circuit clarified the governing disability standard and rejected aspects of the plan’s interpretation, constraining how pension plans assess disability eligibility even where benefits are ultimately denied on the record presented.

Warren Keller worked as a Loss Prevention Manager and stopped working due to multiple medical conditions, including hypertension, cardiac arrhythmia, lumbar degenerative joint disease, a knee meniscal injury, and a torn rotator cuff. He initially received long-term disability benefits.

When the claim transitioned to the plan’s “any occupation” standard, the plan terminated benefits, asserting Keller could perform alternative work despite the combined impact of his orthopedic and cardiovascular impairments.

The court found Keller totally disabled under the plan’s “any occupation” definition and ordered payment of long-term disability benefits, emphasizing the functional impact of multiple conditions rather than isolating individual diagnoses.