Justia ERISA Opinion Summaries

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Plaintiffs are health care providers who furnish medical services to subscribers of employee health benefits plans. Defendants are health insurers, plan administrators, and/or claims administrators for the relevant employee benefit plans. These two cases involved reimbursement disputes: In DB Healthcare, Blue Cross determined that certain blood tests were investigational and thus excluded from coverage; In Advanced Women's Health Center, Anthem determined that the Center used faulty practices to bill for the tests and so was not entitled to reimbursement. At issue was whether a health care provider designated to receive direct payment from a health plan administrator for medical services was authorized to bring suit in federal court under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq. The court held before, and reiterated, that health care providers are not "beneficiaries" within the meaning of ERISA's enforcement provisions. Spinedex Physical Therapy USA Inc. v. United Healthcare of Arizona, Inc. emphasized this rule and held that a non-participant healthcare provider cannot bring claims for benefits on its own behalf but must do so derivatively. The court concluded that the providers in DB Healthcare lacked derivative standing because they do not hold valid assignments. The court also concluded that the Center lacked derivative authority because the claims fell outside the scope of those assigned rights. Accordingly, the court affirmed the judgment. View "DB Healthcare, LLC v. Blue Cross Blue Shield of Arizona, Inc." on Justia Law

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Plaintiffs were Cumberland University employees, participating in its 403(b) defined contribution pension plan. In 2009, the University adopted a five percent matching contribution. In 2014, the University amended the Plan to replace the five percent match: the University would determine the amount of its matching contribution on a yearly basis, retroactive to 2013. The University announced that its matching contribution for the 2013–14 and 2014-2015 years would be zero percent. The Plan stated: An Employer cannot amend the Plan to take away or reduce protected benefits under the Plan and that “all Plan Participants shall be entitled to . . . [o]btain, upon request to the Employer, copies of documents governing the operations of the Plan.” As of January 2017, the University had not produced a summary plan description after the 2009 Summary Plan Description, despite repeated requests, nor did it provide formal written notice of the amendment within a reasonable period. Plaintiffs filed a class action complaint, alleging violations of the Employee Retirement Income Security Act, 29 U.S.C. 1001, by wrongful denial of benefits, cutbacks, failure to provide notice, and breach of fiduciary duty. The district court dismissed without prejudice for failure to administratively exhaust the claims. The Sixth Circuit reversed, holding, as a matter of first impression, that plan participants need not exhaust administrative remedies before proceeding to federal court when they assert statutory violations under ERISA. View "Hitchcock v. Cumberland University 403(b) DC Plan" on Justia Law

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Plaintiffs, a class of employees who participated in ABB's retirement plans, filed suit alleging that ABB and its fiduciaries managed the plans for their own benefit, rather than for the participants. In an earlier appeal, the court directed the district court to "reevaluate" how the participants might have been injured if the ABB fiduciaries breached their fiduciary duties under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq., when they changed the investment options for the plans. The district court misunderstood the court's direction for a definitive ruling on how to measure plan losses and thus entered judgment for the ABB fiduciaries even though the district court found that they breached their duties. Therefore, the court vacated the judgment on that claim and remanded for further consideration regarding whether the participants can prove losses to the plans. The court also vacated and remanded the district court's award of attorney fees because the court reopened one of the participant's substantive claims. View "Tussey v. ABB, Inc." on Justia Law

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On her last day of work with Mova Pharmaceutical Corporation, Nilda Rodriguez-Lopez (Rodriguez) began experiencing symptoms. Rodriguez was diagnosed with several physical and mental conditions and filed a claim for long-term disability (LTD) benefits under Mova’s employee welfare benefits plan (the Plan). Triple-S Vida, Inc. denied Rodriguez’s application for LTD benefits, finding she did not meet the Plan’s definition of disabled. After she exhausted her administrative remedies, Rodriguez filed suit. The district court granted Triple-S’s motion for summary judgment, concluding that Triple-S’s denial of LTD benefits was neither arbitrary nor capricious. Rodriguez appealed, claiming that the Plan did not reflect a clear grant of discretionary authority to Defendant, and therefore, Triple-S’s determination to deny her LTD benefits was subject to the de novo standard of review. The First Circuit vacated the judgment, holding that the Plan did not confer discretionary authority upon Triple-S, and therefore, de novo review applied. Remanded. View "Rodriguez-Lopez v. Triple-S Vida, Inc." on Justia Law

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Steven Williams alleged that his former employer, FedEx Corporate Services, violated the Americans with Disabilities Act (ADA) by discriminating against him based on his actual and perceived disabilities, and by requiring his enrollment in the company’s substance abuse and drug testing program. Williams further alleges that Aetna Life Insurance Company, the administrator of FedEx’s short-term disability plan, breached its fiduciary duty under the Employee Retirement Income and Security Act (ERISA) when it reported to FedEx that Williams filed a disability claim for substance abuse. Both FedEx and Aetna filed motions for summary judgment, which the district court granted. After review, the Tenth Circuit affirmed in part, and reversed and remanded. An employer is liable for an improper medical examination or inquiry, “unless such examination or inquiry is shown to be job-related and consistent with business necessity.” FedEx argued that it satisfied the business necessity exception because its employee testing program “ensure[] that employees who seek assistance for drug abuse or dependencies are no longer abusing the drug if they return to FedEx.” The Tenth Circuit found that the district court did not address this argument. As a result, the Court did not have an adequate record from which it could decide this issue on appeal. The Court reversed for the district court to decide that issue, and affirmed in all other respects. View "Williams v. FedEx Corporate" on Justia Law

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Plaintiff and eight others filed a class action against Anheuser-Busch under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. Plaintiffs are participants in the Anheuser-Busch salaried employee pension plan and claim that they are entitled to enhanced pension benefits. At issue is the interpretation of Section 19.11(f) of the plan. Determining that it has jurisdiction over the appeal, the court concluded that Section 19.11(f) is unambiguous and agreed with the district court's adoption of the reasoning in the Sixth Circuit's case, Adams v. Anheuser-Busch Cos., that Section 19.11(f) entitled plaintiffs to enhanced benefits. Although the court affirmed on the merits, the court agreed with plaintiffs that the decision still must be reversed and remanded because the district court failed to make individual calculations of enhanced benefits owed to individual members of the class. Therefore, the court reversed and remanded with instructions to reconsider plaintiffs' prayer for relief and, to the extent requested and provable, calculate and award the benefits owed to plaintiffs by applying Section 19.11(f). The court noted that, upon remand, the district court may reconsider whether certain records will assist in its calculation of the requested benefits. View "Knowlton v. Anheuser-Busch" on Justia Law

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This appeal concerned a dispute between employees represented by a Union and their successor employer. The parties agreed to arbitrate this dispute regarding change in the terms of pension provision in a collective bargaining agreement. The district court refused to compel arbitration on the grounds that ERISA preempted the Union’s claims, and this, in turn, presented an issue of arbitrability properly decided by a judge, not an arbitrator. The First Circuit vacated the order of the district court and remanded with instructions to grant the Union’s motion to compel arbitration, holding that the issue of ERISA preemption in this case was not an issue of arbitrability but, rather, one that was squarely for the arbitrator to decide. View "Prime Healthcare Services - Landmark LLC v. United Nurses & Allied Professionals, Local 5067" on Justia Law

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Plaintiff filed suit against his employer, Sears, alleging misrepresentation, constructive fraud, and infliction of emotional distress. Specifically, plaintiff alleged that Sears improperly administered life insurance benefits. The district court dismissed the complaint. Sonoco Prods. Co. v. Physicians Health Plan, Inc. held that section 502(a) of the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a), preempts a state law claim when: the plaintiff has standing, the claim must fail under the scope of an ERISA provision that can enforce via section 502(a), and the claim must not be capable of resolution without an interpretation of the contract governed by federal law. Because plaintiff's claims meets all three prongs of the Sonoco test, the court concluded that ERISA completely preempts his claims. Accordingly, the court affirmed the judgment. View "Prince v. Sears Holdings Corp." on Justia Law

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In 1993, Vendura was hired by TRW Inc. and became a participant in the TRW Salaried Pension Plan. In 2002, Northrop Grumman Corp. acquired TRW and renamed the company (herein referred to as NGSMC). After NGSMC attempted to terminate Vendura’s employment Vendura challenged the attempt, and Vendura and NGSMSC signed a settlement agreement providing that Vendura would remain an employee of NGSMSC under certain conditions. In 2013, Vendura filed a claim for pension benefits to the Administrative Committee for the NGSMSC Plan, arguing that he was entitled to twenty years of benefit service under the settlement agreement. The Administrative Committee informed Vendura that he was eligible for a pension reflecting only twelve years of service. Vendura filed an eight-count complaint against Defendants, claiming, inter alia, a violation of ERISA. The district court granted summary judgment for Defendants. At issue on appeal concerned the number of “years of benefit service” that should be credited to Vendura in calculating his pension benefits under his pension plan. The First Circuit granted summary judgment to Defendants, holding that the Administrative Committee properly calculated Vendura’s pension benefits. View "Vendura v. Boxer" on Justia Law

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PCMA filed suit seeking a declaration that the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq., expressly preempts section 510B.8 of the Iowa Code. Iowa Code 510B.8 regulates how pharmacy benefits managers (PBMs) establish generic drug pricing, and requires that certain disclosures on their drug pricing methodology be made to their network pharmacies as well as to Iowa’s insurance commissioner. The court reversed the district court's judgment and remanded for entry of judgment for PCMA on the issue of express preemption, concluding that section 1144(a) of ERISA expressly preempts section 510B.8 because section 510B.8 applies to only those PBMs who administer prescription drug benefits for plans subject to ERISA regulation, and specifically exempts certain ERISA plans from its application. View "Pharmaceutical Care Management v. Gerhart" on Justia Law