Justia ERISA Opinion Summaries

Wilson participates in a health insurance plan governed by the Employee Retirement Income Security Act of 1974 (ERISA). Wilson’s minor son, J.W., a beneficiary of the Plan, received in-patient mental health treatment. The Plan denied coverage. Wilson filed suit under ERISA, 29 U.S.C. 1132(a)(1)(B). The court affirmed the denial of coverage for treatment from December 1, 2015, through May 15, 2016, concluding the plan administrator acted reasonably under the relevant factors. The court dismissed, for failure to exhaust administrative remedies, Wilson’s claims arising from treatment received from May 15, 2016, through J.W.’s discharge on July 31, 2017.The Fourth Circuit affirmed the denial of the claims for 2015-2016 as not medically necessary. J.W. did not require intensive psychological intervention and saw a licensed psychiatrist only about one time each month. The court vacated the dismissal of Wilson’s claims for the administrator’s coverage determinations that were made before January 26, 2017, and that were not for services provided 2015-2016. The court affirmed the dismissal of Wilson’s claim for coverage determinations the administrator made after January 26, 2017, (regardless of when the corresponding services were provided) because Wilson failed to exhaust his administrative remedies for those claims. View "Wilson v. UnitedHealthcare Insurance Co." on Justia Law

Lereta maintained an ERISA-governed benefits plan, subject to the Employee Retirement Income Security Act (ERISA) that provided short-term disability (STD) and long-term disability (LTD) to its employees, including Newsom. Reliance issued the policies that funded these benefits and served as the benefits claims administrator. Newsom filed suit following Reliance’s determination that he was ineligible for LTD benefits.The district judge entered an order in favor of Newsom, awarding him LTD benefits. The Fifth Circuit affirmed as to Newsom’s eligibility for LTD benefits and alleged date of disability but vacated as to Newsom’s entitlement to LTD benefits. The court remanded with instructions for the district court to remand Newsom’s claim to the administrator for further proceedings. The district court did not err by interpreting the term “full time” and its reference to a “regular work week” to mean the “scheduled workweek” set by Lereta for Newsom. Although that factual record contains medical records Newsom submitted during Reliance’s evaluation of his claim, the merits evidence is at best incomplete and undermines the district court’s benefits determination; the court’s benefits determination does not fully square with the record. View "Newsom v. Reliance Stnrd Life Ins" on Justia Law

Soto, a former Disney employee, alleged that Disney improperly denied her severance benefits upon her termination for physical illness that rendered her unable to work. Soto, a longtime employee had experienced a severe stroke and other medical problems, which left her unable to work. Disney formally terminated Soto’s employment, paid Soto sick pay, short-term illness benefits, and long-term disability benefits but did not pay her severance benefits. She filed suit under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1132(a)(1)(B); (a)(3), alleging that the Plan Administrator improperly determined that she did not experience a qualifying “Layoff” as required for severance benefits.The Second Circuit affirmed the dismissal of her case. Her complaint does not plausibly allege that the interpretation of “Layoff” and resulting denial of severance benefits to Soto were arbitrary and capricious. The Plan Administrator had reasoned bases, relating to taxation, for its interpretation of “Layoff” and consequent denial of severance benefits. The court noted an IRS regulation that defines an “involuntary” “termination of employment” as one arising from “the independent exercise of the unilateral authority of the [employer] to terminate to [employee’s] services, . . . where the [employee] was willing and able to continue performing services.” View "Soto v. Disney Severance Pay Plan" on Justia Law

In 2013, Vercellino was injured in an accident while riding on an ATV operated by his friend, Kenney. Both were minors. Vercellino was a covered dependent on his mother’s insurance plan. The plan is self-funded, so ERISA, 29 U.S.C. 1001, preempted state law. The Insurer paid nearly $600,000 in medical expenses and did not exercise its right to seek recovery in subrogation from Kenney or Kenney’s parents during the applicable statutory period, nor did Vercellino’s mother ever file suit to recover medical expenses from the Kenneys. In 2019, Vercellino, then an adult, filed suit against the Kenneys seeking general damages and sought declaratory judgment that the Insurer would have no right of reimbursement from any proceeds recovered in that litigation. The Insurer counterclaimed, seeking declaratory judgment that it would be entitled to recover up to the full amount it paid for Vercellino’s medical expenses from any judgment or settlement Vercellino obtained.The Eighth Circuit affirmed summary judgment for the Insurer. The plain language of the plan at issue here is unambiguous: the Insurer is entitled to seek reimbursement for medical expenses arising out of the ATV accident paid on Vercellino’s behalf from any judgment or settlement he receives in his litigation with Kenney. View "Vercellino v. Optum Insight, Inc." on Justia Law

The First Circuit affirmed the decision of the district court granting Defendant's motion to dismiss as to count one of Plaintiffs' complaint and reversed the dismissal and remanded for further proceedings on counts two through four, holding that dismissal was improper as to the remaining three counts.Plaintiffs, S.R. and T.R. and their child N.R., brought this action against Raytheon Company, T.R.'s employer, after United Healthcare, which administered the company's health insurance plan, refused to pay for N.R.'s speech therapy, alleging various violations of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001, et seq. The district court granted Defendant's motion to dismiss in full. The First Circuit held (1) the district court properly dismissed count one of the complaint; but (2) the dismissal of Plaintiffs' remaining claims was improper. View "N.R. v. Raytheon Co." on Justia Law

Under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001–1461, when an employer withdraws from a multiemployer pension plan, the employer is required to pay for its share of unfunded benefits. Withdrawal liability may be paid in annual installments, calculated in part based on the “highest contribution rate” the employer was required to pay into the plan during a specified time period. When a multiemployer plan is underfunded and in critical status, the employer must pay a surcharge of five or 10 percent of the total amount of contributions the employer was required to make to the plan each year.The district court entered summary judgment in favor of the defendant in an action brought by a multiemployer pension plan, seeking a recalculation of the defendant’s annual withdrawal liability payments. The Ninth Circuit affirmed. For purposes of determining an employer’s annual withdrawal payment, a surcharge paid by the employer when a plan is in critical status is not included in the calculation of the “highest contribution rate.” The surcharge automatically imposed on an employer when a plan is in critical status does not increase the applicable contribution rate, which in this case is the dollar amount per compensable hours. View "Western States Office and Professional Employees Pension Fund v. Welfare & Pension Administration Service, Inc." on Justia Law

The Second Circuit affirmed the district court's judgment in an action brought by the Fund against C&S Wholesale Grocers under the Employee Retirement Income Security Act (ERISA). The court held that the district court did not err in dismissing the Fund's evade-or-avoid liability theory; the district court did not err in dismissing the Fund's common control liability; the district court did not err in finding that C&S was not an employer of the Union employees at the Syracuse warehouse; and successor liability can, as a matter of law, apply to withdrawal liability under ERISA. However, in this case, the district court did not err in granting C&S's motion for summary judgment because C&S did not substantially continue Penn Traffic's relevant business, and therefore was not subject to successor liability. View "NY State Teamsters Conference Pension and Retirement Fund v. C&S Wholesale Grocers, Inc." on Justia Law

Northwestern’s defined contribution retirement plans, governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001, allowed participants to choose an individual investment mix from a menu of options selected by plan administrators. Participants claimed those administrators violated their duty of prudence by offering needlessly expensive investment options and paying excessive record-keeping fees. The Seventh Circuit affirmed the dismissal of those claims, finding that the plaintiffs’ preferred type of low-cost investments were available as plan options.The Supreme Court vacated. A categorical rule is inconsistent with the context-specific inquiry that ERISA requires and fails to take into account the duty of plan fiduciaries to monitor all plan investments and remove any imprudent ones. The Seventh Circuit erroneously focused on another component of the duty of prudence: the obligation to assemble a diverse menu of options. Provision of an adequate array of investment choices, including the lower cost investments plaintiffs wanted, does not excuse the allegedly imprudent decisions. Even if participants choose their investments, plan fiduciaries must conduct their own independent evaluation to determine which investments may be prudently included in the plan’s menu of options. If the fiduciaries fail to remove an imprudent investment from the plan within a reasonable time, they breach their duty. The Court remanded, “so that the Seventh Circuit may reevaluate the allegations as a whole, considering whether petitioners have plausibly alleged a violation of the duty of prudence,” which turns on the circumstances prevailing when the fiduciary acts. View "Hughes v. Northwestern University" on Justia Law

Through a bankruptcy proceeding, Bristol became the successor-in-interest to Haven, an accredited mental-health and substance-abuse treatment center that regularly serviced patients insured by Cigna. Bristol alleged that Cigna violated the Employee Retirement Income Security Act of 1974 (ERISA) and state law by denying Haven’s claims for reimbursement for services provided. Haven was out-of-network for Cigna’s insureds. The district court dismissed Bristol’s ERISA claim, as an assignee of a healthcare provider, for lack of derivative standing, or lack of authority to bring a claim under ERISA, 29 U.S.C. 1132(a)(1)(B).The Ninth Circuit reversed. Under ERISA, a non-participant health provider cannot bring claims for benefits on its own behalf but must do so derivatively, relying on its patients’ assignments of their benefits claims. Other assignees also may have derivative standing if extending standing would align with the goal of ERISA. Refusing to allow derivative standing for Bristol would create serious perverse incentives that would undermine the goal of ERISA. Denying derivative standing to health care providers would harm participants or beneficiaries because it would discourage providers from becoming assignees and possibly from helping beneficiaries who were unable to pay up-front. View "Bristol SL Holdings, Inc. v. Cigna Health and Life Insurance Co." on Justia Law

Plaintiff filed suit against MasterCard for life insurance benefits under MasterCard's employee benefits plan, alleging breach of fiduciary duty under the Employee Retirement and Income Security Act (ERISA), breach of contract, and fraud.The Eighth Circuit reversed the district court's grant of summary judgment in favor of MasterCard on plaintiff's breach of fiduciary claim, concluding that plaintiff plausibly alleged that his wife elected a total amount of three times her salary in life insurance, for which MasterCard promised to pay premiums. The court explained that, if that proves true, MasterCard's failure to pay premiums would constitute a breach of the fiduciary duty it owed its employees participating in its ERISA-governed benefit plan. Furthermore, plaintiff plausibly alleged that, if his wife's election was in fact deficient for any reason, MasterCard's materially misleading statements caused her to reasonably believe that she had elected three times her salary in life insurance, premiums paid by her employer, and to rely upon that belief in declining to purchase additional life insurance as she was entitled to do. The court affirmed as to the remaining claims and concluded that amendment would be futile. View "Delker v. Mastercard International, Inc." on Justia Law