Sample complaint

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 268-288

Form 16 ERISA Disability Claims and Litigation A-250

FORM 16 SAMPLE COMPLAINT



Insurer, Defendant Employer Securities (USA) LLC (“Employer”), the Employer

Medical Insurance Plan (“Medical Plan”), the Employer Dental Insurance Plan



1. This is an action arising under the Employee Retirement Income Security Act

of 1974, as amended (“ERISA”), 29 U.S.C. §1001, et seq.

   



2. This Court has subject matter jurisdiction pursuant to Section 502(e)(1) of

ERISA, 29 U.S.C. § 1132(e)(1) and 28 U.S.C. § 1331. Under Section 502(f)

of ERISA, 29 U.S.C. § 1132(f), this Court has jurisdiction without respect to

the amount in controversy or the citizenship of the parties.

   

U.S.C. § 1132(e)(2), in that the Defendants reside or may be found in this District.

PLAINTIFF’S PARTICIPATION IN THE

LONG TERM DISABILITY PLAN

   

of Section 3(7) of ERISA, 29 U.S.C. § 1002(7), in the Employer Long Term

Disability Plan (the “LTD Plan”).

5. At all relevant times, the LTD Plan is and has been an “employee welfare ben-



6. At all relevant times, LTD Insurer is and has been the claims administrator of

the LTD Plan within the meaning of Section 3(16)(A) of ERISA, 29 U.S.C. §

1002(16)(A).

 

Section 3(21)(A) of ERISA, 29 U.S.C. § 1002(21)(A).

 -



 

 

insurance coverage under the LTD Plan.

 

“Disabled” or “Disability” means that, due to sickness, preg-

nancy or accidental injury, you are receiving Appropriate Care

and Treatment from a Doctor on a continuing basis and you are

unable to earn more than 80% of your Predisability Earnings

or Indexed Predisability Earnings at your Own Occupation for

any employer in your Local Economy. Your loss of earnings

A - 2 51 Appendix: Sample Documents Form 16

must be a direct result of your sickness, pregnancy or accidental

injury. Economic factors such as, but not limited to, recession,

job obsolescence, paycuts and job-sharing will not be considered

in determining whether you meet the loss of earnings test.

 

“Own Occupation” means the activity that you regularly perform

and that serves as your source of income. It is not limited to

 

similar activity that could be performed with your Employer or

any other employer.

STANDARD OF REVIEW

13. During the claims and administrative review processes, LTD Insurer failed to

comply with the Department of Labor’s claims-procedure regulations, and its

failure to comply was neither inadvertent nor harmless.

14. Upon information and belief, LTD Insurer has not adopted claim procedures

in accordance with the Department of Labor regulations.

15. By way of LTD Insurer’s procedural violations, LTD Insurer forfeited its enti-

tlement to any deference granted by the LTD Plan document.

16. For these reasons, this case is subject to a de novo review.

PLAINTIFF’S BACKGROUND AND

DEGENERATIVE SPINAL CONDITIONS

 

18. By 2017, she had already earned her Masters at University and became a highly



 

star in her industry.

 

due to worsening degenerative spinal conditions, including Scheuermann’s

disease and rapid degenerative disc disease, which necessitated two complex,

major spinal surgeries in 2017.

20. Scheuermann’s disease is a genetic condition that limits the growth of cartilage

endplate, causing osteochondrosis of the spine. The condition usually begins

in childhood. See https://www.ncbi.nlm.nih.gov/pubmed/24468666. See also

copy in Administrative Record (“AR”).

21. “For most patients, Scheuermann’s disease runs a fairly benign course, with

resolution of symptoms at skeletal maturity. However, these individuals are

more likely to have disk herniations in adulthood that may be neurologically

devastating. At the apex of the kyphosis, adults often have pain along with

varying degrees of degenerative spondylolysis and spondylolisthesis. The