Justia ERISA Opinion Summaries

Orr died in a motorcycle accident. His daughters sought benefits under a group life insurance policy governed by the Employment Retirement Income Security Act and issued by USIC to Orr’s former employer. The policy provided accidental death, subject to exclusions, including one for loss resulting “directly or indirectly from … intoxication[.]” USIC asserted that Orr’s death resulted from his intoxication. The letter explained that autopsy and toxicology reports revealed that Orr’s blood alcohol level at the time of the accident exceeded the legal limit and that USIC’s medical consultant opined that Orr “would have been impaired in attention, coordination, and balance,” as a result. The letter advised the Orrs of their right to seek review and included a copy of USIC’s Life Claims Denial Review Procedure, stating, in boldfaced, all-caps print, that a request for review must be submitted in writing within 60 days and warning: “If … you do not complete both the first and second review before filing a lawsuit, a court can dismiss your lawsuit.“ The document encourages claimants to call with any questions. The Orrs filed suit before completing the review process. The Seventh Circuit affirmed summary judgment in favor of USIC on grounds of failure to exhaust administrative remedies. View "Orr v. Assurant Emp. Benefits" on Justia Law

Insurance companies allegedly refused to honor claims for payment of blood-clotting-factor products. After they paid the claims in full, the district court dismissed a complaint under the Employees Retirement Income Security Act (ERISA) and state law. Following dismissal, both the plaintiffs and defendants sought attorney’s fees and costs. The Third Circuit affirmed denial, but remanded one issue: whether the plaintiffs were entitled to interest on the delayed payment of benefits. On remand, they sought interest of $1.5 to $1.8 million, primarily under the Maryland Code, with $68,000 based on the federal Treasury bill rate. The companies agreed to pay $68,000.00 in interest and the district court dismissed the case. Plaintiffs then sought attorney’s fees and costs of $349,385.15. The district court denied the motion, finding that plaintiffs had failed to achieve “some degree of success on the merits” as required for an award of fees under ERISA. The Third Circuit reversed, holding that the court used an incorrect legal standard to evaluate eligibility for attorney’s fees and misapplied the “Ursic” factors. The “catalyst theory” of recovery is available to the plaintiffs and judicial action is not required under that theory in order to establish some degree of success. View "Templin v. Independence Blue Cross" on Justia Law

In 2000, Rochow sold his interest in Universico to Gallagher and became President of Gallagher. As Gallagher employee, Rochow was covered under a LINA disability policy. In 2001, Rochow began to experience short term memory loss, chills, sweating, and stress. Gallagher demoted Rochow and forced Rochow to resign in January, 2002. In February 2002, Rochow experienced amnesia, was hospitalized, and was diagnosed with HSV-Encephalitis, a rare, severely debilitating brain infection. LINA repeatedly denied Rochow benefits stating that Rochow’s employment ended before his disability began. Rochow sued Cigna, LINA’s parent company, alleging breach of fiduciary duty under ERISA, 29 U.S.C. 1104(a). In 2007 the Sixth Circuit affirmed a decision that denial of Rochow’s claims was arbitrary and did not appear to have been made solely in the interest of the participants and beneficiaries or the exclusive purpose of providing benefits to participants and beneficiaries as required by ERISA. Rochow died in 2008. In 2009, the district court ordered an equitable accounting of profits and disgorgement of $3,797,867 under an equitable theory of unjust enrichment. The Sixth Circuit affirmed in 2013. Following rehearing en banc, the Sixth Circuit later vacated the disgorgement award and remanded the case to determine whether Rochow is entitled to prejudgment interest. View "Rochow v. Life Ins. Co. of North Am." on Justia Law

From 1995-2009, Johnson worked for CRE. In the last three years, Johnson worked from home, 8 hours a day at a computer. Johnson was covered under CRE’s United disability insurance policy. In 1999, Johnson was diagnosed with fibromyalgia. In 2004, she underwent neck surgery for nerve injuries. On the day she resigned, Johnson visited MacDonald, her primary care physician, who diagnosed anxiety, depression, fibromyalgia, and chronic pain. Johnson completed a short-term disability form. MacDonald completed an Attending Physician’s Statement. United denied the application. Based on the recommendations of its doctor, United denied Johnson’s appeal. Johnson sought long-term disability benefits. MacDonald completed a Physician’s Statement that imposed multiple limitations. United denied the claim. Johnson appealed. United referred Johnson’s file and medical records to Boscardin, an orthopedic surgeon, who determined that, although Johnson experienced chronic pain in her neck and spine, Johnson’s complaints were not supported by “conclusive, objective evidence.” McClellan, Johnson’s surgeon, responded that he “[o]verall” agreed with Boscardin. United denied the appeal. Johnson sued under ERISA. The district court granted Johnson summary judgment, finding that United failed to consider Johnson’s condition as a whole. The Eighth Circuit reversed, finding the denial supported by substantial evidence. View "Johnson v. United of Omaha Life Ins. Co." on Justia Law

In 1988, Brake began working at Hutchinson. She was diagnosed with multiple sclerosis (MS) in 2000, but continued to work. Brake purchased disability insurance through Hutchinson’s plan in 1988. Hutchinson, as the plan administrator, ceded discretionary authority to Hartford to construe the plan and make eligibility determinations. In 2007, Brake purchased "buy-up" coverage that excluded a disability if medical treatment for that condition was rendered within 12 months prior to the effective date. The limitation ended after a year without a claim: if Brake was treated for MS between April 1, 2006, and April 1, 2007, and then became disabled as a result of MS before April 1, 2008, the exclusion would limit her benefits to core plan coverage. Brake began experiencing problems with her MS in 2007 and received benefits from a separate short-term disability plan. On March 25, 2008, she stopped working at Hutchinson. In May, she applied for LTD benefits, stating her onset of disability as July 27, 2007. Hartford informed her that her LTD benefits were approved, but not at the buy-up plan rate. Brake claimed that doctor visits during the 12 months were for a pap smear and a yearly routine MRI. Hartford cited the same records which indicated that Brake was increasingly less able to manage her MS conditions during the 12 months before her purchase of buy-up coverage. In Brake’s suit under ERISA, 29 U.S.C. 1001, the district court found that Hartford did not abuse its discretion. The Eighth Circuit affirmed summary judgment in favor of Hartford. View "Brake v. Hutchinson Tech., Inc.," on Justia Law

Ibson and her family were insured by UHS through a policy available to her to as a member of her law firm. Due to an error, UHS began informing Ibson’s medical providers that Ibson and her family no longer had insurance coverage. Although UHS eventually paid the claims it should have paid all along, Ibson sued, raising state law claims of breach of contract, negligence, and bad faith, and seeking punitive damages. UHS responded that Ibson’s claims were preempted by the Employee Retirement Income Security Act (ERISA) and barred by the policy’s three-year contractual limitations period. The district court agreed and entered summary. The Eighth Circuit reversed and remanded, agreeing that Ibson’s state law claims are preempted under ERISA, but rejecting entry of summary judgment on the basis of the three-year contractual limitations period. View "Ibson v. United Healthcare Servs., Inc." on Justia Law

Bibeau appealed the district court's grant of summary judgment and order directing it, as a related person to a disabled miner's former employer, to pay health insurance premiums, interest, and liquidated damages to the United Mine Workers of America 1992 Benefit Plan. The court concluded that Bibeau's laches claim was precluded under Petrella v. Metro-Goldwyn-Mayer, Inc. because each premium installment gives rise to a separate cause of action for legal relief for which Congress has enacted a statute of limitations to govern timeliness. Further, under the Coal Industry Retiree Health Benefit Act of 1992, 26 U.S.C. 9701-9722, which incorporates the Employee Retirement Income Security Act's (ERISA), 29 U.S.C. 1451(a)(1), enforcement scheme, the district court did not err in awarding interest and liquidated damages. Accordingly, the court affirmed the judgment. View "Holland v. Bibeau Construction Co." on Justia Law

This case arose from injuries suffered by several students during scholastic athletic activities. The students were insured by Central States, an Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., employee welfare benefit plan that provides health insurance to participating Teamsters and their dependents. The students were also directly insured by separate accident policies written by Gerber. Central States subsequently filed suit against Gerber, alleging various claims for declaratory judgment and injunctive relief pursuant to federal common law and ERISA section 502(a)(3). The court held that although Central States might well be left without an appropriate remedy as a result of this decision, and that in the future its beneficiaries may be put in the unfortunate position of having to sue their insurance companies to receive benefits to which they are indisputably entitled, the claims raised by Central States are legal, not equitable, and therefore may not be brought under section 502(a)(3). Accordingly, the court affirmed the district court's grant of Gerber's motion to dismiss under Rule 12(b)(6). View "Cent. States, Se. & Sw Areas Health & Welfare Fund v. Gerber Life Ins. Co." on Justia Law

Plaintiff Sonia Graciano was injured after she was hit by a car driven by Saul Ayala. Ayala was insured by defendant California Automobile Insurance Company (CAIC). Three weeks after Graciano's attorney first contacted CAIC regarding the accident, Graciano misidentified both the driver and the applicable insurance policy. CAIC investigated the accident, identified the applicable policy and the correct driver, and offered to settle Graciano's claim with a "full policy limits offer." Graciano did not accept CAIC's full policy limits offer and, in this suit, alleged CAIC and its parent and affiliated companies acted in bad faith, based on an alleged "wrongful failure to settle." Graciano argued CAIC could have and should have earlier discovered the facts, and should have made the full policy limits offer more quickly. The jury found in favor of Graciano and this appeal followed. CAIC argued that, as a matter of law, there was no evidence to support the verdict that CAIC acted in bad faith by unreasonably failing to settle Graciano's claim against Saul. The Court of Appeal agreed, and reversed the judgment. View "Graciano v. Mercury General Corp." on Justia Law

Plaintiffs filed suit against Deputy Arnold and Sheriff Graves, alleging violations of federal and state law after Arnold fatally shot their father while responding to a 911 call that the father was threatening to commit suicide. Plaintiffs also filed suit against ReliaStar to recover $179,000 they allege ReliaStar owes them under the father's accidental death policy. The district court granted Arnold and Grave's motions for summary judgment and granted ReliaStar's motion for summary judgment. The court held that Arnold did not violate the father's Fourth Amendment rights when he entered the father's home without a warrant because he had an objectively reasonable belief that the father would imminently seriously injure himself, and the district court did not err in granting Arnold's motion for summary judgment on the warrantless entry claim because Arnold is entitled to qualified immunity; Arnold is entitled to qualified immunity because he did not violate the father's constitutional right to be free from excessive force; the district court did not err in granting summary judgment for Arnold on the assault and battery claims, the false imprisonment claims, and the intentional infliction of emotional distress claim; the district court correctly granted Graves's motion for summary judgment; and the district court did not err in granting summary judgment for ReliaStar where the record was replete with factual evidence that ReliaStar relied on in determining that the father's death was not accidental, demonstrating that ReliaStar could have reached its determination without resorting to the conflict of interest at issue. Accordingly, the court affirmed the judgment of the district court. View "Rice, et al. v. Reliastar Life Ins. Co." on Justia Law