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The Ninth Circuit reversed the district court's judgment for MetLife in an Employee Retirement Income Security Act (ERISA) action. MetLife denied coverage because plaintiff's leg injury was complicated by his diabetes. The panel held, however, that plaintiff was entitled to coverage because his diabetes did not substantially cause his leg injury from an automobile accident nor did diabetes contribute to his injury. Accordingly, the panel remanded for further proceedings. View "Dowdy v. Metropolitan Life Insurance Co." on Justia Law

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The Ninth Circuit reversed the district court's judgment for MetLife in an Employee Retirement Income Security Act (ERISA) action. MetLife denied coverage because plaintiff's leg injury was complicated by his diabetes. The panel held, however, that plaintiff was entitled to coverage because his diabetes did not substantially cause his leg injury from an automobile accident nor did diabetes contribute to his injury. Accordingly, the panel remanded for further proceedings. View "Dowdy v. Metropolitan Life Insurance Co." on Justia Law

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Sports Medicine performed shoulder surgery on “Joshua,” who was covered by a health insurance plan, and charged Joshua for the procedure. Because it did not participate in the insurers’ network, Sports Medicine was not limited to the insurer’s fee schedule and charged Joshua $58,400, submitting a claim in that amount to the insurers on Joshua’s behalf. The claim form indicated that Joshua had “authorize[d] payment of medical benefits.” The insurer processed Joshua’s claim according to its out-of-network cap of $2,633, applying his deductible of $2,000 and his 50% coinsurance of $316, issuing him a reimbursement check for the remaining $316, and informing him that he would still owe Sports Medicine the remaining $58,083. Sports Medicine appealed through the insurers’ internal administrative process and had Joshua sign an “Assignment of Benefits & Ltd. Power of Attorney.” Sports Medicine later sued for violations of the Employee Retirement Income Security Act (ERISA), and breach of contract, citing public policy. The district court dismissed for lack of standing because Joshua’s insurance plan included an anti-assignment clause. The Third Circuit affirmed, holding that the anti-assignment clause is not inconsistent with ERISA and is enforceable. View "American Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield" on Justia Law

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The Fourth Circuit affirmed the district court's grant of summary judgment for the insurance company that insured Steven Gordon. After Steven died, his wife filed suit seeking the full coverage amount for the insurance policy he had been paying for through his company. The court held that no reasonable jury could find that either of the CIGNA Defendants had a fiduciary duty toward the Gordons with respect to soliciting supporting materials for coverage beyond the guaranteed issue amount or notifying new employees that they had not completed the evidence of insurability requirement; even assuming without deciding, that the cause of action for breach of trust by a fiduciary under the Employee Retirement Income Security Act (ERISA) was cognizable, her claim would fail because there was no evidence that the CIGNA Defendants knowingly participated in any breach; and the district court did not err by granting summary judgment before allowing plaintiff to conduct discovery. View "Gordon v. Cigna Corp." on Justia Law

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The Fourth Circuit affirmed the district court's grant of summary judgment for the insurance company that insured Steven Gordon. After Steven died, his wife filed suit seeking the full coverage amount for the insurance policy he had been paying for through his company. The court held that no reasonable jury could find that either of the CIGNA Defendants had a fiduciary duty toward the Gordons with respect to soliciting supporting materials for coverage beyond the guaranteed issue amount or notifying new employees that they had not completed the evidence of insurability requirement; even assuming without deciding, that the cause of action for breach of trust by a fiduciary under the Employee Retirement Income Security Act (ERISA) was cognizable, her claim would fail because there was no evidence that the CIGNA Defendants knowingly participated in any breach; and the district court did not err by granting summary judgment before allowing plaintiff to conduct discovery. View "Gordon v. Cigna Corp." on Justia Law

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In 1991, Norton merged predecessor retirement plans into one Plan governed by ERISA. As of 1997, the Plan included a traditional defined-benefit formula applicable to members of the predecessor plans and a cash-balance formula applicable to all other plans. In 2004, the Plan was amended to end accruals under the defined-benefit formulas and allow further accruals only under the cash-balance benefit formula. The Plan allows disability retirement, “normal” age 65 retirement, late retirement, and early retirement, for participants at least 55 years old with at least 10 years of service. The Plan allows retirees to take benefits in the “Basic Form” or in one of six alternative forms, including a lump-sum payment on the date of retirement. In 2008, the Retirees brought a putative class action, alleging Norton underpaid retirees who took a lump-sum payment. The court certified a class in 2011 and eventually granted the Retirees summary judgment. Damages were not reduced to a sum certain, but the court adopted the Retirees’ calculation formula, awarded fixed-rate pre-judgment interest, and entered final judgment. The Sixth Circuit vacated, finding the Plan ambiguous, with respect to calculation of benefits, and possibly noncompliant with ERISA, with respect to actuarial calculations. The court vacated class certification under Rule 23(b)(1)(A) and (b)(2). The court held that if the Plan clearly gives the administrator “Firestone” deference, interpretation against the draftsman has no place in reviewing the administrator’s decisions. The arbitrary-and-capricious standard stays intact. View "Clemons v. Norton Healthcare Inc. Retirement Plan" on Justia Law

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The Fourth Circuit affirmed the district court's judgment requiring Just Born, a candy manufacturer, to pay delinquent contributions into the Bakery and Confectionary Union and Industry International Pension Fund, as well as interest, statutory damages, and attorneys' fees. Under a plain-language application of the Provision to the facts of this case, the court held that Just Born was liable to the Pension Fund for continued contributions for all employees hired after the declaration of an impasse, pending the execution of a new collective bargaining agreement (CBA) in compliance with section 1085 of the Employee Retirement Income Security Act (ERISA), the invocation of the withdrawal provisions, or some other statutorily required act. Accordingly, the Pension Fund was entitled to judgment on the pleadings so long as Just Born did not present a cognizable affirmative defense. The court agreed with the district court's reasoning that the Rule 9(b) standard applied to Just Born's affirmative defenses and that Just Born's allegations did not satisfy this standard. Therefore, the district court did not err in concluding that Just Born did not plead its affirmative defenses with sufficient particularity to withstand the Pension Fund's motion for judgment on the pleadings. View "Bakery and Confectionary Union v. Just Born II, Inc." on Justia Law

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The Fourth Circuit affirmed the district court's judgment requiring Just Born, a candy manufacturer, to pay delinquent contributions into the Bakery and Confectionary Union and Industry International Pension Fund, as well as interest, statutory damages, and attorneys' fees. Under a plain-language application of the Provision to the facts of this case, the court held that Just Born was liable to the Pension Fund for continued contributions for all employees hired after the declaration of an impasse, pending the execution of a new collective bargaining agreement (CBA) in compliance with section 1085 of the Employee Retirement Income Security Act (ERISA), the invocation of the withdrawal provisions, or some other statutorily required act. Accordingly, the Pension Fund was entitled to judgment on the pleadings so long as Just Born did not present a cognizable affirmative defense. The court agreed with the district court's reasoning that the Rule 9(b) standard applied to Just Born's affirmative defenses and that Just Born's allegations did not satisfy this standard. Therefore, the district court did not err in concluding that Just Born did not plead its affirmative defenses with sufficient particularity to withstand the Pension Fund's motion for judgment on the pleadings. View "Bakery and Confectionary Union v. Just Born II, Inc." on Justia Law

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In 2012 Northern changed its defined-benefit pension plan under which retirement income depended on years worked, times an average of the employee’s five highest-earning consecutive years, times a constant (traditional formula). As amended, the plan multiplies the years worked and the high average compensation, by a formula that depends on the number of years worked after 2012 (PEP formula), reducing the pension-accrual rate. Northern provided people hired before 2002 a transitional benefit, treating them as if they were still under the traditional formula but deeming their salaries as increasing at 1.5% per year, without regard to the actual rate of change. Teufel sued, claiming that the amendment, even with the transitional benefit, violated the anti-cutback rule in the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001–1461, and, by harming older workers relative to younger ones, violated the Age Discrimination in Employment Act (ADEA), 29 U.S.C. 621–34. The Seventh Circuit affirmed dismissal of the suit. Nothing in the traditional formula guaranteed that any salary would increase in future years; ERISA protects entitlements that make up the “accrued benefit” but does not protect anyone’s hope that the future will improve on the past. Nor does the PEP formula violate the ADEA. Benefits depend on the number of years of credited service and salary, not on age. View "Teufel v. Northern Trust Co." on Justia Law

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The Eighth Circuit affirmed the district court's grant of summary judgment against plaintiff in an action seeking funds from her husband's trust that was transferred from an Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001-1461, plan. The husband had requested the "Accrued Benefit" amount from his ERISA employee-benefit plan be transferred to his trust days before he passed away. Applying an abuse of discretion standard to this case, the court held that the plan administrative committee reasonably explained its interpretation and relied on substantial evidence to deny plaintiff's claim. Therefore, the committee did not abuse its discretion when it determined that the relevant inquiry was not when funds were received by a participant, but rather when funds were transferred out of the plan. View "Wengert v. Rajendran" on Justia Law