Justia ERISA Opinion Summaries

Nicole discovered Shawn’s body in their Ohio home. Shawn had gone out drinking the night before, while Nicole spent the night at a friend’s house. The Medical Examiner’s Office reported the cause of death as “[a]sphyxia by extreme and restricted position (positional asphyxia)” and the manner of death as “[a]cute ethanol intoxication ... ACCIDENT: Prolonged and extreme hypertension of neck and torso while intoxicated.” Shawn’s blood-alcohol level at the time of autopsy was .22%. Nicole filed a $212,000 claim for accidental-death benefits with the Plan, which covers “injury” as a result of an “accident,” defined as “an unintended or unforeseeable event or occurrence which happens suddenly and violently.” No benefits will be paid if the “Covered Person [is] deemed and presumed, under the law of the locale … to be under the influence of alcohol or intoxicating liquors.” Nationwide directed denial of Nicole’s claim, citing Exclusion 12, but quoting an earlier version that provided: “The Covered Person being deemed and presumed … to be driving or operating a motor vehicle while under the influence…” Later, based on amended Exclusion 12, Nationwide upheld the denial; its appeals panel affirmed. Nicole filed suit, asserting claims under the Employee Retirement Income Security Act and a common-law breach-of-fiduciary-duty claim. The district court entered judgment in favor of the defendants, but agreed with Nicole that the appeals panel had breached its statutory duty to provide her with Plan-related documents upon written request, and imposed a penalty of $55 per day ($8,910). The Sixth Circuit affirmed. View "Cultrona v. Nationwide Life Ins. Co." on Justia Law

GM provides its salaried retirees with continuing life insurance benefits under an ERISA-governed plan. MetLife issued the group life insurance policy and periodically sent letters to participants advising them of the status of their benefits. The plaintiffs, participants in the plan, allege that those letters falsely stated that their continuing life insurance benefits would remain in effect for their lives, without cost to them. GM reduced their continuing life insurance benefits as part of its 2009 Chapter 11 reorganization. The plaintiffs sued MetLife under the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1132(a)(2) & (a)(3) and state law. The district court dismissed. The Sixth Circuit affirmed. MetLife did not tell participants that the benefits were fully paid up or vested upon retirement, but that their benefits would be in effect for their lifetimes, which “was undeniably true under the terms of GM’s then-existing plan.” The court rejected claims of estoppel, of breach of fiduciary duty, unjust enrichment, breach of plan terms, and restitution.View "Merrill Haviland v. Metro. Life Ins. Co." on Justia Law

CareFirst, Inc., a nonstock, nonprofit Maryland corporation, is a holding company with two subsidiaries that provides health insurance for millions of Maryland residents. State law confers broad authority on the Maryland Insurance Commissioner to oversee its operation and adherence to its mission. This case arose from the termination of Leon Kaplan, a former executive of CareFirst. CareFirst declined to pay part of the post-termination compensation set forth in Kaplan's employment contract, reasoning that the compensation was not for "work actually performed," as that standard had been interpreted by the Commissioner. The Commissioner affirmed the decision not to pay the benefits, concluding that the payments would violate Md. Code Ann. Ins. 14-139. The Court of Appeals affirmed, holding (1) the Commissioner's determination was not preempted by ERISA; (2) the Commissioner's construction of the insurance code was legally correct; and (3) there was substantial evidence to support the Commissioner's determination in this case.View "Md. Ins. Comm'r. v. Kaplan" on Justia Law

Lewis was injured in an automobile accident and her health plan paid $180,000 for her medical treatment Lewis filed a tort suit against the driver (her son-in-law), represented by Georgia lawyer Lashgari, and obtained a $500,000 settlement. Lashgari knew the plan had a subrogation lien, but split the proceeds between himself and Lewis. He claimed that the plan was owed nothing. The plan filed suit under ERISA to enforce the lien, 29 U.S.C. 1132(a)(3). The defendants argued that because the settlement funds have been dissipated, the suit was actually for damages, not authorized by ERISA. The district judge ordered the defendants to place $180,000 in Lashgari’s trust account pending judgment. The defendants did not comply. A year later, the defendants having neither placed any money in a trust account nor produced any evidence of their inability to pay, the judge held them in civil contempt, ordered them to produce records that would establish their financial situations, and ordered Lashgari to documents relating to the contempt to the General Counsel of the State Bar for possible disciplinary proceedings against him. The defendants appealed the contempt order. The Seventh Circuit dismissed, characterizing the appeal as frivolous and the defendants’ conduct as outrageous. View "Cent. States, SE & SW Areas Health & Welfare Fund v. Lewis" on Justia Law

The Commission appealed the district court's order preliminarily enjoining him from enforcing several provisions of the Georgia Code as preempted by Section 514 of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1144(a). The court found that AHIP had standing to challenge Section 4, 5, and 6 of the Insurance Delivery Enhancement Act of 2011 (IDEA), O.C.G.A. 33-24-59.5; AHIP's suit was not barred by the Tax Injunction Act, 28 U.S.C. 1341; AHIP was likely to succeed on the merits of its claims where the challenged IDEA provisions were preempted by ERISA Section 514; and the district court did not abuse its discretion in concluding that AHIP met its burden to show irreparable injury and that the balance of equities weighed in favor of a preliminary injunction. Accordingly, the court affirmed the judgment of the district court. View "America's Health Ins. Plan v. Hudgens" on Justia Law

Richard worked for GPI for 25 years until his 2009 death. He had a basic life insurance policy through GPI’s health and welfare plan and paid for an optional supplemental life insurance policy through GPI for several years. His wife, Maureen, was the beneficiary of both policies. At the end of 2008, Richard’s supplemental life insurance policy was cancelled. Richard’s pay stubs reflected the change, beginning in January 2009. When Richard died a few months later, GPI’s insurer, ABC, paid benefits on the basic life insurance policy. Richard had been diagnosed with stage 4 cancer in September 2008. Soon after Richard’s death, Maureen’s attorney requested information regarding Richard’s supplemental life insurance policy. The company refused the request, citing its confidentiality policy, indicating that the information would only be produced in response to a subpoena. Almost two years later, Maureen filed suit, claiming that either GPI or ABC breached the policy by terminating it without Richard’s consent, in violation of the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court awarded the defendants summary judgment. The Seventh Circuit affirmed. There was no material issue of fact as to whether Richard cancelled his supplemental policy. Although Maureen speculated that someone other than Richard terminated the policy, she presented no evidence to support her assertion. View "Herzog v. Graphic Packaging Int'l, Inc." on Justia Law

An employee benefits plan sued a medical college that provides patient care in clinics and hospitals and an affiliated children’s hospital, with which it had provider agreements, alleging ERISA violations and breach of contract under Wisconsin law. The suit was based on the plan’s determination that an employee’s child was not covered by the plan and the hospital’s denial of its subsequent request that the hospital refund about $1.7 million the plan had already paid on behalf of the child. The plan makes no mention of refunds. The district court dismissed and awarded attorneys’ fees to the hospital as a sanction for having filed frivolous claims. The Seventh Circuit affirmed dismissal of the ERISA claims but reversed dismissal of the breach of contract claim, rejecting the district court’s finding of preemption, and imposition of sanctions. On remand of the contract claim, the district court granted summary judgment in favor of the hospital. The Seventh Circuit affirmed, noting that the hospital, having been paid in full by the plan, has no possible claim against Medicaid, that the plan took 11 months to determine that the child was not a beneficiary, and that the hospital has not been unjustly enriched. View "Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of WI" on Justia Law

A Vermont statute requires all "health insurers" to file with the State reports containing claims data and other "information relating to health care." Liberty Mutual sought a declaration that the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq., preempted the Vermont statute and regulation. The district court granted summary judgment in favor of Vermont. The court held that the reporting requirements of the Vermont statute and regulation have a "connection with" ERISA plans and were therefore preempted as applied. The court's holding was supported by the principle that "reporting" is a core ERISA function shielded from potentially inconsistent and burdensome state regulation. Accordingly, the court reversed and remanded with instructions to enter judgment for Liberty Mutual. View "Liberty Mutual Ins. Co. v. Donegan" on Justia Law

Javery began working for Lucent as a software engineer in 1998 and participated in Lucent’s Employee Retirement Income Security Act, 29 U.S.C. 1001, qualified disability plan, administered by CIGNA. In November 2002, he reported back pain. His family doctor, Dr. Dorado, prescribed medicine and testing, and recommended some time off work. In January 2003, after Lucent transferred him from Ohio to Illinois, Javery sought treatment from another physician, Seymour. The pain worsened. In May 2005, Javery stopped working on Dr. Seymour’s advice. Lucent approved and paid short term disability benefits from until those benefits expired in November 2005. Lucent notified CIGNA that it believed Javery might be eligible for long term benefits. Javery applied, submitting extensive medical evidence of his pain and resulting cognitive impairment and of his successful application for Social Security disability benefits, but the claim was denied. In addition to claiming that Javery had not shown that he was “disabled” as that term is defined in the Plan, CIGNA claimed that Javery should be judicially estopped from pursuing his ERISA claim because Javery failed to disclose the claim in his Chapter 13 personal bankruptcy action. The district court upheld the denial. The Sixth Circuit reversed. View "Javery v. Lucent Tech., Inc. Long-Term Disability Plan" on Justia Law

As an assembler with Eaton Corporation, McClain purchased the highest level of long-term disability insurance, which was “designed to replace ... 70 percent of [her] monthly base pay.” She stopped working in January 2008, due to a back injury she suffered on the job in June 2007. She received benefits during the first 24 months under the First Tier of the Plan’s coverage, which defined disability as being “totally and continuously unable to perform the essential duties of your regular position with the Company, or the duties of any suitable alternative position with the Company.” After 24 months, the Plan to an “any occupation” standard, providing Second Tier coverage if “you are totally and continuously unable to engage in any occupation or perform any work for compensation or profit for which you are, or may become, reasonably well fit by reason of education, training or experience--at Eaton or elsewhere.” The Plan denied her claim for benefits because her treating physician opined McClain could work part-time, and a market study identified various part-time positions in the area for which she was qualified. The district court rejected her suit under the Employee Retirement Income Security Act, 29 U.S.C. 1001. The Seventh Circuit affirmed, finding that the determination was not arbitrary.View "McClain v. Eaton Corp. Disability Plan" on Justia Law