Justia ERISA Opinion Summaries

Plaintiffs M.S. and L.S. sought insurance coverage for mental health treatments for their child, C.S., under a health benefits plan provided by M.S.'s employer, Microsoft Corporation. The plan, administered by Premera Blue Cross, is subject to ERISA and the Parity Act. Premera denied the claim, stating the treatment was not medically necessary. Plaintiffs pursued internal and external appeals, which upheld the denial. Plaintiffs then sued in federal district court, alleging improper denial of benefits under ERISA, failure to produce documents in violation of ERISA’s disclosure requirements, and a Parity Act violation for applying disparate treatment limitations to mental health claims.The United States District Court for the District of Utah granted summary judgment to Defendants on the denial-of-benefits claim but ruled in favor of Plaintiffs on the Parity Act and ERISA disclosure claims. The court found that Defendants violated the Parity Act by using additional criteria for mental health claims and failed to disclose certain documents required under ERISA. The court awarded statutory penalties and attorneys’ fees to Plaintiffs.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court vacated the district court’s grant of summary judgment on the Parity Act claim, finding that Plaintiffs lacked standing to bring the claim. The court reversed the district court’s ruling that Defendants violated ERISA by not disclosing the Skilled Nursing InterQual Criteria but affirmed the ruling regarding the failure to disclose the Administrative Services Agreement (ASA). The court upheld the statutory penalty for the ASA disclosure violation and affirmed the award of attorneys’ fees and costs to Plaintiffs. View "M.S. v. Premera Blue Cross" on Justia Law

Art Iron, Inc. faced a lawsuit from the Board of Trustees of the Shopmen’s Local 499 Pension Plan seeking over one million dollars in withdrawal liability under ERISA. The key issue was whether Robert Schlatter, Art Iron’s sole shareholder, and his wife, Mary Schlatter, were personally liable for this withdrawal liability due to their operation of businesses allegedly under common control with Art Iron.The United States District Court for the Northern District of Ohio granted summary judgment in favor of the Board, finding both Robert and Mary Schlatter personally liable. The court determined that Robert’s consulting business and Mary’s jewelry-making activities were trades or businesses under common control with Art Iron, thus making them jointly and severally liable for the withdrawal liability.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court affirmed the district court’s judgment regarding Robert Schlatter, agreeing that his consulting business was a trade or business under common control with Art Iron. The court applied the Groetzinger test, which considers whether the activity is continuous and regular and primarily for income or profit, and found that Robert’s consulting business met these criteria.However, the court reversed the district court’s judgment regarding Mary Schlatter. It found that her jewelry-making activities did not constitute a trade or business under the Groetzinger test, as her activities lacked the necessary continuity and regularity in 2017, the year of Art Iron’s withdrawal from the Plan. Consequently, Mary Schlatter was not personally liable for the withdrawal liability.The Sixth Circuit thus affirmed the district court’s judgment as to Robert Schlatter and reversed and remanded the judgment as to Mary Schlatter. View "Shopmen’s Local No 499, Bd of Trustees v. Art Iron, Inc." on Justia Law

Plaintiffs Marla Knudsen and William Dutra, representing a class of similarly situated individuals, filed a class action lawsuit under the Employee Retirement Income Security Act (ERISA) against MetLife Group, Inc. They alleged that MetLife, as the administrator and fiduciary of the MetLife Options & Choices Plan, misappropriated $65 million in drug rebates from 2016 to 2021. Plaintiffs claimed this misappropriation led to higher out-of-pocket costs for Plan participants, including increased insurance premiums.The United States District Court for the District of New Jersey dismissed the case for lack of standing. The court concluded that the plaintiffs did not demonstrate a concrete and individualized injury. It reasoned that the plaintiffs had no legal right to the general pool of Plan assets and had not shown that they did not receive their promised benefits. The court found the plaintiffs' claims that they paid excessive out-of-pocket costs to be speculative and lacking factual support.The United States Court of Appeals for the Third Circuit affirmed the District Court's dismissal. The Third Circuit held that the plaintiffs failed to establish an injury-in-fact, as their allegations of increased out-of-pocket costs were speculative and not supported by concrete facts. The court noted that the plaintiffs did not provide specific allegations showing how the misappropriated drug rebates directly caused their increased costs. The court emphasized that financial harm must be actual or imminent, not conjectural or hypothetical, to satisfy Article III standing requirements. Consequently, the plaintiffs lacked standing to pursue their ERISA claims. View "Knudsen v. MetLife Group Inc" on Justia Law

Kelly Dwyer sought to recover mental health benefits for his minor daughter, E.D., under his employee group benefit health plan issued by United Healthcare Insurance Company. E.D. suffered from severe anorexia nervosa, leading her parents to admit her to a residential treatment facility, Avalon Hills. Initially, United approved full hospitalization benefits, but later reduced the coverage to partial hospitalization and eventually denied further hospitalization benefits, suggesting outpatient treatment instead. Despite E.D.'s doctors' objections and evidence of her ongoing severe symptoms, United maintained its decision.The United States District Court for the Western District of Texas conducted a bench trial and ruled in favor of United, finding that the insurer had not improperly withheld benefits. The court's decision was based on the administrative record and the arguments presented during the trial.The United States Court of Appeals for the Fifth Circuit reviewed the case and reversed the district court's judgment. The appellate court found that United's denial of benefits was both substantively and procedurally deficient. Substantively, the court held that United's decision was not supported by concrete evidence and contradicted the medical records. Procedurally, United failed to provide a meaningful dialogue or adequate explanation for its denial, violating ERISA requirements. Additionally, the court found that United improperly failed to process claims at the MultiPlan rate, as it did not respond to Mr. Dwyer's administrative appeal regarding this issue.The Fifth Circuit reversed the district court's judgment and remanded the case for the calculation of damages, statutory penalties, attorneys' fees, and other relief for Mr. Dwyer. View "Dwyer v. United Healthcare" on Justia Law

Erica Barrett and other employees of O’Reilly Automotive, Inc. alleged that the company’s 401(k) plan managers breached their fiduciary duty by imposing high recordkeeping expenses and inflated expense ratios on the plan, resulting in less money for the participants. They claimed that these high costs were due to either incompetence or laziness on the part of the plan managers.The United States District Court for the Western District of Missouri dismissed the complaint. The court found that the plaintiffs failed to provide meaningful benchmarks to support their claim that the plan’s fees were excessive. Specifically, the court noted that the plaintiffs did not adequately compare the costs of O’Reilly’s plan with those of similar plans offering the same services.The United States Court of Appeals for the Eighth Circuit reviewed the dismissal de novo. The court affirmed the district court’s decision, agreeing that the plaintiffs did not provide meaningful benchmarks to show that the plan’s fees were excessive. The court emphasized that the plaintiffs’ comparisons were flawed because they did not account for the different services included in the fees of the comparator plans. Additionally, the court found that aggregate data from the Investment Company Institute was insufficient to establish a plausible claim of mismanagement. The court also dismissed the failure-to-monitor claim against O’Reilly and its board of directors, as it was derivative of the primary claim. Finally, the court held that the district court did not abuse its discretion in dismissing the complaint with prejudice, as the plaintiffs did not formally request leave to amend their complaint. View "Barrett v. O'Reilly Automotive, Inc." on Justia Law

James Moyer and other captive insurance agents sued GEICO, claiming they were misclassified as independent contractors and denied benefits under the Employee Retirement Income Security Act of 1974 (ERISA). They argued that GEICO should have classified them as employees, making them eligible for various benefits plans. The agents did not attach the relevant benefits-plan documents to their complaint, which are integral to their claims.The United States District Court for the Southern District of Ohio ordered the parties to provide the relevant plan documents. GEICO submitted documents it claimed governed the dispute, but the agents argued that the court could not rely on these documents without converting the motion to dismiss into a summary judgment motion and requested additional discovery. The district court disagreed, relied on the documents provided by GEICO, and dismissed the complaint, finding that the agents lacked statutory standing as they were not eligible for the benefits under the plan documents.The United States Court of Appeals for the Sixth Circuit reviewed the case and found that there were legitimate questions about whether GEICO had provided a complete set of the relevant plan documents. The court noted issues with the authenticity and completeness of the documents, including redlines, handwritten notes, and missing pages. The court held that the district court should not have relied on these documents to dismiss the complaint without allowing the agents to conduct discovery. Consequently, the Sixth Circuit reversed the district court's decision and remanded the case for further proceedings. View "Moyer v. GEICO" on Justia Law

Mychal Byrd was injured in an automobile accident caused by an unknown motorist and subsequently died from his injuries. Byrd's medical expenses, totaling $474,218.24, were covered by the Gilster-Mary Lee Corporation Group Health Benefit Plan, a self-funded plan subject to ERISA. Byrd had an automobile insurance policy with Nationwide Insurance Company, which provided $50,000 in uninsured-motorist coverage. After Byrd's death, his family sued Nationwide in state court to collect the insurance proceeds. The Plan intervened, removed the case to federal court, and claimed an equitable right to the insurance proceeds.The United States District Court for the Eastern District of Missouri granted summary judgment in favor of the Plan, determining that the Plan was entitled to the insurance proceeds under the plan document. The plaintiffs, initially proceeding pro se, did not respond to the motion for summary judgment. After obtaining counsel, they moved for reconsideration, which the district court denied. The plaintiffs then appealed the decision.The United States Court of Appeals for the Eighth Circuit reviewed the case and concluded that the district court lacked subject-matter jurisdiction. The appellate court determined that the plaintiffs' claim did not fall within the scope of ERISA's civil enforcement provisions because the plaintiffs were neither plan participants nor beneficiaries. Consequently, the claim was not completely preempted by ERISA, and the federal court did not have jurisdiction. The Eighth Circuit vacated the district court's judgment and remanded the case with instructions to return it to Missouri state court. View "Kellum v. Gilster-Mary Lee Corporation Group Health Benefit" on Justia Law

Paul Carnes, an employee of Consolidated Grain and Barge Co., was diagnosed with degenerative disc disease in 2019 and received medical treatment for it. HMO Louisiana, Inc., the administrator of Consolidated Grain’s employer-sponsored health plan governed by ERISA, paid for some of Carnes’s treatments but not all. Carnes filed a workers’ compensation claim against his employer, which was settled without the employer accepting responsibility for his medical claims. With an outstanding medical balance of around $190,000, Carnes sued HMO Louisiana, alleging it violated Illinois state insurance law by not paying his medical bills and sought penalties for its alleged "vexatious and unreasonable" conduct.The United States District Court for the Central District of Illinois dismissed Carnes’s complaint on the grounds that his state law insurance claim was preempted by ERISA. The court allowed Carnes to amend his complaint to plead an ERISA claim, but instead, Carnes moved to reconsider the dismissal. The district court denied his motion and ordered the case closed. Carnes then appealed the final order.The United States Court of Appeals for the Seventh Circuit reviewed the case de novo. The court affirmed the district court’s decision, agreeing that Carnes’s state law claim was preempted by ERISA. The court noted that ERISA’s broad preemption clause supersedes any state laws relating to employee benefit plans, and Carnes’s claim fell within this scope. The court also found that ERISA’s saving clause did not apply because the health plan in question was self-funded, making it exempt from state regulation. The court concluded that Carnes’s attempt to frame his suit as a "coordination of benefits dispute" was an impermissible effort to avoid ERISA preemption. Consequently, the court affirmed the dismissal of Carnes’s case. View "Carnes v. HMO Louisiana, Inc." on Justia Law

Two employees, Tanika Parker and Andrew Farrier, participated in 401(k) plans managed by subsidiaries of Tenneco Inc. The plans were amended to include mandatory individual arbitration provisions, which required participants to arbitrate disputes individually and barred representative, class, or collective actions. Parker and Farrier alleged that the fiduciaries of their plans breached their fiduciary duties under ERISA by failing to prudently manage the plans, resulting in higher costs and reduced retirement savings. They sought plan-wide remedies, including restitution of losses and disgorgement of profits.The United States District Court for the Eastern District of Michigan denied the fiduciaries' motion to compel individual arbitration. The court found that the arbitration provisions limited participants' substantive rights under ERISA by eliminating their ability to bring representative actions and seek plan-wide remedies, which are guaranteed by ERISA.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court's decision. The Sixth Circuit held that the individual arbitration provisions were unenforceable because they acted as a prospective waiver of the participants' statutory rights and remedies under ERISA. The court emphasized that ERISA allows participants to sue on behalf of a plan and obtain plan-wide relief, and the arbitration provisions' restrictions on representative actions and plan-wide remedies violated these statutory rights. Consequently, the arbitration provisions were invalid, and the district court's judgment was affirmed. View "Parker v. Tenneco, Inc." on Justia Law

Joel M. Guy, Jr. murdered his parents in 2016 with the intent to collect the proceeds from his mother’s insurance plans. His mother had life insurance and accidental death and dismemberment insurance through her employer, naming Guy and his father as beneficiaries. Guy was convicted of first-degree premeditated murder, felony murder, and abuse of a corpse by a Tennessee jury.The United States District Court for the Eastern District of Tennessee determined that Guy would be entitled to the insurance proceeds if not disqualified. However, the court ruled that Guy was disqualified under Tennessee’s slayer statute or federal common law, which prevents a murderer from benefiting from their crime. The court granted summary judgment in favor of Guy’s family members, who argued that Guy was not entitled to the benefits. Guy appealed, arguing that ERISA preempts Tennessee’s slayer statute and that no federal common-law slayer rule applies.The United States Court of Appeals for the Sixth Circuit reviewed the case de novo. The court held that ERISA does not explicitly address the issue of a beneficiary who murders the insured, and thus, either Tennessee law or federal common law must apply. The court found that both Tennessee’s slayer statute and federal common law would disqualify Guy from receiving the insurance proceeds. The court affirmed the district court’s decision, concluding that Guy’s actions disqualified him from benefiting from his mother’s insurance plans under both state and federal law. View "Standard Insurance Co. v. Guy" on Justia Law