Justia ERISA Opinion Summaries

Plaintiff discovered she had a brain tumor and underwent radiation. Plaintiff was later hired by Situs Group. Situs maintained a disability plan covered by the Employment Retirement Income Security Act (“ERISA”) that provided long-term disability benefits to eligible current and former employees. The plan’s insurance was provided by Dearborn National Life Insurance., Plaintiff attended a benefits meeting led by Situs’s Benefits Coordinator, where she was told participants could receive benefits regardless of pre-existing conditions and that they would not be questioned about their pre-existing conditions when the company was determining eligibility.Plaintiff’s employer denied her claim for long-term disability benefits under ERISA. The claim was denied because of the application of a preexisting condition exclusion in the insurance contract. Plaintiff raised several points of error on appeal, but the Fifth Circuit affirmed the district court’s ruling.The court agreed with the district court that Dearborn substantially complied with ERISA procedures and was entitled to extend the deadline to respond to Plaintiff’s claim. Further, there is no question that Defendants waived their right to assert the pre-existing condition exclusion as a defense to Plaintiff’s claim for the initial, shorter-term benefits. That waiver does not compel the conclusion that Defendants also intended to waive their right to enforce the exclusion when it came to Plaintiff’s application for LTD benefits. Finally, here neither the magistrate judge nor the district court appeared to consider itself limited to certain categories of evidence. The magistrate judge specifically noted that certain evidence would be relevant to her estoppel or waiver claims but need not be in the administrative record itself. View "Bunner v. Dearborn Natl Life" on Justia Law

Plaintiff appealed the dismissal of his lawsuit seeking long-term disability benefits under the Employee Retirement Income Security Act of 1974 (“ERISA”) from Hartford Life and Accident Insurance Company. The district court concluded that Plaintiff had failed to exhaust his disability plan’s administrative remedies. Plaintiff asserted that his administrative remedies should have been deemed exhausted because Hartford, in violation of the applicable ERISA regulation, failed to provide a final decision on his benefits within 45 days of his administrative appeal.   The Second Circuit reversed the district court’s dismissal of Plaintiff’s. The dispositive question on appeal was whether a valid benefit determination on review must determine whether a claimant is entitled to benefits. Based on the regulation’s plain language, structure, and purpose, the court held that it must. The court further held that, because Hartford did not extend the benefit determination period, duty to exhaust had ceased by the 46th day, the day he filed his federal case.The court further explained that the text of the Sec 503-1 supports Plaintiff’s argument that he did not receive a timely benefit determination on review. Finally, Section 503-1’s text, structure, history, and purpose are fully consistent. A “benefit determination on review” must finally decide the claimant’s benefits within 45 days, assuming the absence of special circumstances that require an extension. By the 46th day after his appeal, Hartford had not determined Plaintiff’s benefits nor extended its review time. So, Plaintiff was deemed to have exhausted his plan remedies and could bring suit in federal court. View "McQuillin v. Hartford Life and Accident Insurance Co." on Justia Law

Tymoc died in a single-car accident. At the time of the accident, Tymoc was traveling between 80-100 miles per hour; the speed limit was 60 miles per hour speed. As Tymoc attempted to pass multiple cars, the gap between a car in the right lane and a box truck in the left lane closed. Tymoc veered to the right, causing his vehicle to drive off the road, roll down an embankment, striking multiple trees, and flip over several times.Through his employer, Tymoc was covered by Unum life insurance; the policy provided both basic life insurance coverage and an additional accidental death benefit. Unum approved a $100,000 payment of group life insurance benefits but withheld $100,000 in accidental death benefits, explaining that Tymoc’s conduct—speeding and reckless driving—caused his death, thereby triggering the policy’s crime exclusion. In a suit under the Employee Retirement Income Security Act, 29 U.S.C. 1001– 1191d, the district court entered in Fulkerson’s favor as to the accidental death benefits. The Sixth Circuit reversed. Reckless driving falls within the unambiguous plain meaning of crime. View "Fulkerson v. Unum Life Insurance Co. of America" on Justia Law

The Universal Health Services Retirement Savings Plan is a defined contribution retirement plan. Qualified employees can participate and invest a portion of their paycheck in selected investment options, chosen and ratified by the UHS Retirement Plans Investment Committee, which is appointed and overseen by Universal. Named plaintiffs, on behalf of themselves and all other Plan participants, sued Universal under the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(2)3 and 1109, alleging that Universal breached its fiduciary duty by including the Fidelity Freedom Fund suite in the plan, charging excessive record-keeping and administrative fees, and employing a flawed process for selecting and monitoring the Plan’s investment options, resulting in the selection of expensive investment options instead of readily-available lower-cost alternatives. They also alleged certain Universal defendants breached their fiduciary duty by failing to monitor the Committee.The Third Circuit affirmed class certification, rejecting an argument that the class did not satisfy the typicality requirement of Federal Rule of Civil Procedure 23(a), given that the class representatives did not invest in each of the Plan’s available investment options. Because the class representatives allege actions or a course of conduct by ERISA fiduciaries that affected multiple funds in the same way, their claims are typical of those of the class. View "Boley v. Universal Health Services Inc" on Justia Law

Canter worked as a premises technician, installing wires, lifting heavy loads, and climbing tall ladders. After he began to suffer from severe migraines, lightheadedness, and dizziness, Canter concluded that he no longer could perform that work. He applied for short-term disability benefits in February 2017 through an AT&T plan. The plan administrator granted benefits for a few months, but AT&T terminated benefits after an independent medical reviewer concluded that Canter’s medical tests were normal and that his symptoms had improved. After Canter unsuccessfully appealed this decision using AT&T’s internal processes, he sued under the Employment Retirement Income Security Act (ERISA), 29 U.S.C. 1132.The district court granted the defendants summary judgment in favor of the defendants. The Seventh Circuit affirmed the decision but reversed the court’s award of $181 in pro hac vice fees to the defendants as not taxable “costs” under 28 U.S.C. 1920. Extensive medical testing consistently yielded normal results, even though the medical providers and reviewers thought that a significant problem would have shown up in one or more concrete, physiological ways. Canter himself reported that he was experiencing improvement. View "Canter v. AT&T Umbrella Benefit Plan No.3" on Justia Law

Plaintiff sued Defendant insurance company for mishandling his wife’s enrollment for supplemental life insurance and then declaring her ineligible for coverage after she died. The district court determined Defendant violated ERISA, finding Defendant breached its fiduciary duty to ensure its system of administration did not allow it to collect premiums until coverage was actually effective. Defendant appealed.The Eighth Circuit affirmed. Defendant maintained its fiduciary duty despite the fact that the deceased's employer collected premium payments before forwarding them to Defendant. The plan in question gave Defendant discretion to approve benefits, which under ERISA is sufficient to create a fiduciary duty. Defendant violated its fiduciary duty by failing to maintain an effective enrollment system. Under ERISA, a fiduciary must discharge its duties with reasonable care, skill, prudence and diligence. The court held that a reasonably prudent insurer would use a system that avoids the employer and insurer having different lists of eligible, enrolled participants. Defendant's billing system breached the fiduciary duty it owed to the deceased. Thus, the court affirmed the district court's granting of summary judgment to Plaintiff. View "Corey Skelton v. Reliance Standard Life Ins Co" on Justia Law

RiverStone operates quarries in three midwestern states. Under a collective bargaining agreement (CBA), RiverStone contributed to the Fringe Benefit Funds for certain employees, based on hours worked by the members of the bargaining unit. The CBA expired in May 2016. Nothing in the agreement imposes on RiverStone an obligation to make contributions after the agreement. RiverStone sought a declaratory judgment that it had no obligation to make contributions to the employees’ pension fund on behalf of individuals hired after the CBA expired. The Funds filed a counterclaim.The district court granted RiverStone summary judgment, holding that RiverStone did not have a contractual duty to contribute to the Funds on behalf of the new employees and that it lacked jurisdiction to evaluate noncontractual sources of liability, such as the National Labor Relations Act (NLRA) so the dispute fell within the exclusive jurisdiction of the National Labor Relations Board. The Seventh Circuit affirmed. The dispute is over an obligation that does not arise under any contract. Once a CBA has expired, the Employee Retirement Income Security Act, 29 U.S.C. 1145, does not confer jurisdiction on the district court to determine whether the employer’s failure to make post-contract contributions violated the NLRA. View "RiverStone Group, Inc v. Midwest Operating Engineers Fringe Benefit Funds" on Justia Law

The Cintas “defined contribution” retirement plan has a “menu” of investment options in which each participant can invest. Each Plan participant maintains an individual account, the value of which is based on the amount contributed, market performance, and associated fees. Under the Employment Retirement Income Security Act (ERISA), 29 U.S.C. 1102(a)(1), the Plan’s fiduciaries have the duty of loyalty—managing the plan for the best interests of its participants and beneficiaries—and a duty of prudence— managing the plan with the care and skill of a prudent person acting under like circumstances. Plaintiffs, two Plan participants, brought a putative class action, contending that Cintas breached both duties. Plaintiffs had entered into multiple employment agreements with Cintas; all contained similar arbitration provisions and a provision preventing class actions.The district court declined to compel arbitration, reasoning that the action was brought on behalf of the Plan, so that it was irrelevant that the two Plaintiffs had consented to arbitration through their employment agreements–the Plan itself did not consent. The Sixth Circuit affirmed. The weight of authority and the nature of ERISA section 502(a)(2) claims suggest that these claims belong to the Plan, not to individual plaintiffs. The actions of Cintas and the other defendants do not support a conclusion that the plan has consented to arbitration. View "Hawkins v. Cintas Corp." on Justia Law

Plaintiff argued that the insurance contract between the parties was governed by a document provided on January 9, 2014, instead of February 19, 2014; that she is entitled to a judgment based on the insurance company’s miscalculation of her copay; and that even if the February 19 document controls, the Patient Protection and Affordable Care Act, 42 U.S.C. Section 18022(c)(1) (“ACA”), mandates that the insurance company must apply the individual out-of-pocket limit rather than the family out-of-pocket limit; and that the generic-brand cost differential Plaintiff paid for her name-brand medication should count toward her out-of-pocket limit. Plaintiff filed a breach of contract claim under ERISA, and the district court granted Defendant judgment on the breach of contract claims under ERISA.   The Second Circuit affirmed the district court’s judgments. The court held that the February document governed the relationship between the parties because Plaintiff was on notice as to its terms. Further, Plaintiff is not entitled to a money judgment for her copay because Defendant agreed to pay Plaintiff the copay differential.   The court also found that the ACA does not provide that the annual limitation on cost-sharing applies to all individuals regardless of whether the individual is covered under an individual “self-only” plan or is covered by a plan that is other than self-only for plans effective before 2016. Finally, the court held that the ACA nor the February document required Defendant to apply the brand-generic cost differential costs to Plaintiff’s out-of-pocket limit. View "Jacqueline Fisher v. Aetna Life Insurance Company" on Justia Law

Plaintiff suffered from back and neck pain for years, and her doctor concluded that surgery would help her relieve her symptoms. After surgery, her insurance provider, Central States, denied her claim. Central States made this determination pursuant to a provision of the plan stating that covered individuals “shall not be entitled to payment of any charges for care, treatment, services, or supplies which are not medically necessary or are not generally accepted by the medical community as Standard Medical Care, Treatment, Services or Supplies.” Central States came to this conclusion based on an independent medical review (IMR) of Plaintiff’s claim, conducted by a physician board-certified in general surgery. Plaintiff filed suit under the Employee Retirement Income Security Act (“ERISA”), and Defendant appealed the district court’s ruling.The Fourth Circuit found that Central States failed to disclose to their IMR physician the medical records that would have been pertinent to his analysis. The court noted that it did not conclude that Central States acted in bad faith or deliberately withheld documentation. But intent aside, Central States owes plan participants a “deliberate, principled reasoning process.” Further, while plan trustees enjoy a good measure of discretion in determining what is “medically necessary” under the terms of the plan, they may not abuse that discretion by employing processes that lead to unreasoned conclusions or by affixing extratextual requirements. The court held that because Central States had ample chance to review Plaintiff’s claim, the district court did not abuse its discretion by awarding benefits outright. View "Dorothy Garner v. Central States, Southeast and Southwest Areas" on Justia Law