Brian Greben | Great Neck Criminal Lawyer

Rosenberg v. Guardian Life Ins. Co. of Am., 2002 U.S. Dist. LEXIS 24683 Practice Area: Insurance Outcome: The employer's motion to dismiss was granted. The employer was represented by Mr. Greben Description: Plaintiff employee sued defendant employer, challenging the employer's denial of the employee's long term disability benefits under an employee welfare benefits plan, which was governed by the Employee Retirement Income Security Act, 29 U.S.C.S. § 1001, et seq. The employer moved for summary judgment. The employer discontinued the employee's total disability benefits because the employee had not been receiving treatment for either his unstable bowel syndrome, or his mental/emotional disorder, even though his physicians recommended continued treatment. The employee claimed that the denial of his benefits was arbitrary and capricious because the plan provided no definition of the "under the care of a doctor" requirement. The court held that while the employer had styled its motion a motion for summary judgment, its motion was in substance an appeal from an administrative judgment. Further, the employee did not explain how the plan's requirement that he be under a doctor's regular care for the cause of his or her disability was ambiguous, and did not offer his own definition of the words used in this phrase. The plain meaning of the condition that the employee be under the regular care of a doctor for the cause of the disability required, at a minimum, that the employee consult with a physician more than sporadically and that the consultations seek care for the cause of the condition which the employee claimed disabled him. Buchinger v. Guardian Life Ins. Co. of Am. Practice Area: Insurance Outcome: (not available) Description: The insured argued that the claims in question were not subject to the policy limitation. The health insurance plan at issue was governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.S. § 1001 et seq. Because the plan gave the insurer discretionary authority to determine eligibility for benefits and to construe the plan with respect to claims, the question was whether the insurer's determination was arbitrary and capricious. Because an ERISA plan was involved and because the insurer's interpretation of the policy was not arbitrary and capricious, the insurer's interpretation controlled, even if the insured's interpretation was also reasonable.