ERISA-Third Circuit Holds That ERISA Governs The Plan At Issue, And That The Decision Of Whether The Plaintiff Was Incorrectly Denied His Benefits Must Be Made By The District Court

The case of McCann v. Unum Provident, No. 16-2014 (3rd Cir. 2018) involves two principal issues: first, whether a group insurance plan is governed by ERISA and, second, whether the physician—claimant was incorrectly denied his disability benefit payments.

In this case, plaintiff-appellant, Dr. Kevin McCann, is a radiologist certified in the specialty of interventional radiology.  The gravamen of this appeal concerns a supplemental long-term disability insurance policy Dr. McCann purchased from defendant, Provident Life and Accident Insurance Company.  After initially issuing payments under the policy, Provident terminated Dr. McCann’s disability benefits.  Central to its decision was a determination that Dr. McCann was primarily practicing as a diagnostic radiologist—rather than as an interventional radiologist—at the time he became disabled.  This suit followed.

In analyzing the case, the Third Circuit Court of Appeals (the “Court”) said that, as a preliminary matter, the parties dispute whether Dr. McCann’s claim arises under ERISA.  Thus, the Court first considers the outer bounds of an employer’s involvement in a group or group—type insurance plan before deciding whether the plan may be governed by ERISA.  The Department of Labor has promulgated a safe harbor regulation exempting certain plans from the definition of an “employee welfare benefit plan.”  But the Court concluded that Dr. McCann’s then—employer sufficiently endorsed the plan under which his policy was purchased to render the safe harbor inapplicable.  The plan is therefore governed by ERISA, which will supply the governing framework.

As to the merits, the Court found that Provident incorrectly defined Dr. McCann’s occupation in administering his disability claim and that the claim must be evaluated in the context of his specialty—interventional radiology.  The Court will remand for the District Court to consider whether Dr. McCann’s medical conditions prevent him from being able to perform his “substantial and material duties” as an interventional radiologist, as required by the terms of the policy.

 

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