Life, Health, Disability & ERISA Litigation Attorneys, Practice Areas

LIFE, HEALTH, DISABILITY, AND ERISA LITIGATION

MORAN • KARAMOUZIS LLP represents many of the most prominent insurers of individual life, health and disability policies throughout the country and specializes in all forms of group and individual policy litigation, including lawsuits alleging breaches of duty under ERISA and challenges to plan denials of claims for benefits. The members of the Firm have been active in both litigation and resolution of claims in cutting-edge areas of first-party benefits, such as the application of the arbitrary and capricious standard of review to State or Governmental health plans, ADA claims, RICO, consumer fraud statute, subrogation, and class actions.

Siobhan E. Moran has extensive knowledge and expertise in suits involving individual and group life insurance policies, gained while she worked in-house with a prominent life insurance company, where she worked closely with life, health and disability business clients.

As an associate with Shearman & Sterling, Ms. Moran tried to a jury the pro bono case of White v. Blue Cross and Blue Shield of Greater New York, 146 Misc.2d 125, 549 N.Y.S.2d 598 (N.Y. Sup. 1989), which included the issue of punitive damages against an insurer in a first-party benefits litigation. Mr. Karamouzis second-chaired that trial with Ms. Moran.

Since 1998, Mr. Karamouzis has expanded his commercial litigation practice to include defending companies in connection with lawsuits seeking benefits under both individual and group disability benefit policies. In that regard, Mr. Karamouzis recently represented a health insurer in Long Island Pulmonary Associates v. Metropolitan Life Insurance Company, 303 A.D. 2d 645, 756 N.Y.S 2d 788 (2d Dep't 2003), a case of first impression in New York, where the Court granted summary judgment in favor of the health insurer in its action against a health care provider for fraudulent billing practices.

Mr. Karamouzis' litigation practice also includes defending insurance companies in connection with lawsuits seeking benefits under both individual and group disability benefit policies. In that regard, Mr. Karamouzis recently represented a health insurer, in Long Island Pulmonary Associates v. Metropolitan Life Insurance Company, 303 A.D. 2d 645, 756 N.Y.S 2d 788 (2d Dep't 2003), a case of first impression in New York, where the Court granted summary judgment in favor of the health insurer in its action against a health care provider for fraudulent billing practices.

REPRESENTATIVE MATTERS

Provider Litigation

Represent health insurers in connection with New York and New Jersey State court actions brought by non-participating providers seeking to avoid ERISA protections by claiming negligent misrepresentation in connection with benefit payments.
Obtained summary judgment on behalf of health care insurer dismissing a complaint brought by healthcare providers alleging that the letters and explanations of benefits sent to their patients/insureds, in connection with an audit of the providers' billing practices, were slanderous, libelous, constituted tortious interference with their contracts, and violated antitrust statutes.
Obtained summary judgment in several actions based on the anti-assignment, reasonable and customary charge and/or statute of limitations provisions in health insurance plans.

Skilled Nursing Litigation

Successfully tried a skilled nursing benefits case challenging the reduction of skilled nursing benefits from twenty-four to two hours per day, which decision was affirmed by the New York State Appellate Division, First Department.
Successfully opposed motions for a preliminary injunction in several actions seeking to enjoin the health insurer's decision to reduce the level of skilled nursing benefits provided.
After two substantive motions and an appeal in which the Court directed broad discovery on corporate mergers, and the development of benefits programs, obtained summary judgment dismissing RICO, fraud, and New York State Consumer Fraud Statute claims relating to the application of skilled nursing guidelines to determine whether skilled nursing benefits were available under the health plan at issue.
Obtained summary judgment upholding health plan's determination that Plaintiff's stay in skilled nursing facility was not covered under the terms of the health plan at issues, as her medical condition did not require skilled care.

Life Insurance Litigation

Obtained summary judgment in several life insurance litigations rescinding the life insurance policy on the basis of misrepresentations made in the application.
Obtained a defense verdict, after a non-jury trial, dismissing Plaintiff's claims seeking to rescind a life insurance policy based on misrepresentations made in the life insurance application.
Obtained summary judgment dismissing replacement action against life insurer based on defense that company had no connection to replacement policy as the selling agent was not the company's employee but, rather, an "independent insurance agent." Court rejected Plaintiff's "apparent authority" argument.
Obtained summary judgment dismissing claims that lapsed life insurance policies totaling $2,225,000 should be reinstated based upon disability riders to policies.
Obtained summary judgment to recover an overpayment of life insurance benefits, while defeating Defendants' arguments that reduction in value of life insurance policy to minimize premium payments violated §8708(b)(2) of the Federal Employee Group Life Insurance Act.

ERISA Litigation

Obtained summary judgment dismissing claims for health benefits in numerous actions involving ERISA-governed employer sponsored welfare benefit plans, including matters regarding the appropriate treatment for Lyme disease, provisions for nursing home benefits, reduction of skilled nursing benefits, pain management, and treatment for substance abuse.
Obtained summary judgment in long-term disability case involving claims of headache and back pain with the Court agreeing with the Company that the relevant plan language imparted discretionary authority to the plan administrator to determine eligibility for benefits, rejecting Plaintiff's claims that documents beyond the administrative record should be considered by the Court and that the Company improperly required objective medical evidence, and agreed that the Company was not required to defer to the opinion's of Plaintiff's treating physicians.
Successfully resolved numerous ERISA-governed employer sponsored long-term disability benefits actions, frequently through mediation.
Obtained judgment permitting the recovery of an overpayment of life insurance benefits to improper party. The Court held that ERISA preempts Defendant's equitable estoppel claim, finding that her expenditure of the benefits for a new car and other expenses did not bar repayment.
Successfully argued that the arbitrary and capricious standard of review applied to non-ERISA governmental entity's medical necessity determinations of covered pain management options.

Overpayment Litigation

Obtained judgment permitting the recovery of an overpayment of life insurance benefits, with the Court rejecting Defendants' arguments that the Company's reduction in the value of the life insurance policy to minimize premium payments violated § 8708(b)(2) of the Federal Employee Group Life Insurance Act.
Obtained judgment permitting the recovery of overpaid disability benefits, including a finding that the Plaintiff had injured other plan participants through her wrongful retention of benefits.
Resolved numerous health insurance subrogation matters such that health insurers recovered substantial portions of benefits paid due to wrongful actions of third-parties.
Successfully moved on behalf of a health plan to reinstate the medical expenses awarded by a jury, but thereafter eliminated pursuant to a CPLR § 4545 collateral source hearing.

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