Justia ERISA Opinion Summaries

A third-party administrator of medical benefits plans, IMA, denied claims made on behalf of two patients who received treatment from the same medical provider, LifeCare. The court held that IMA incorrectly interpreted the plans because it categorized LifeCare as a skilled nursing facility (SNF) without finding that LifeCare "fully meets all of" the plans' seven SNF factors. IMA abused its discretion because categorizing LifeCare as an SNF without considering the seven-factors SNF test contradicted the plain language of the plans. The court found that the district court correctly held that LifeCare could maintain an action against IMA pursuant to 29 U.S.C. 1132(a)(1)(B) and that IMA was liable for exercising actual control over the claims process. The court further held that the district court did not abuse its discretion in awarding attorneys' fees. View "Lifecare Mgmt. Svcs., LLC v. Ins. Mgmt. Admins. Inc, et al" on Justia Law

Plaintiff, a former software developer for Lockheed Martin Corporation, brought this action for judicial review after Connecticut General terminated his disability benefits in 2007. The court held that the district court properly applied an abuse of discretion standard; on the record, it was not an abuse of discretion to terminate plaintiff's benefits; and the district court did not err in denying plaintiff an opportunity to depose the expert at issue. Accordingly, the court affirmed the judgment. View "Siegel v. Connecticut General Life Ins., et al" on Justia Law

In 1992 Navistar attempted to reduce its costs for retired employee health and life insurance benefits. Navistar’s retirement benefit plan is a registered employee health benefit plan under the Employee Retirement Income Security Act, 29 U.S.C. § 1001 and Navistar is both plan administrator and fiduciary. In 1993, the district court entered judgment in a class action challenging the change, adopting an agreement between the parties and retaining jurisdiction. The Agreement established the Retiree Health Benefit and Life Insurance Plan. The Plan established the Health Benefit Program Summary Plan Description, which contains a description of the health benefits and is furnished to all beneficiaries. The Agreement divides health benefits into two plans: Plan 2 for those eligible for Medicare and Plan 1 for those who are not eligible. A prescription drug benefit was provided under the Agreement, identical for both Plan 1 and Plan 2. When Navistar moved to substitute Medicare Part D into the Plan, class members claimed violation of the Agreement. The district court ordered Navistar to reinstate, retroactively, the prescription drug benefit that was in effect before Navistar made the unilateral substitution. The Sixth Circuit affirmed,View "Shy v. Navistar Int'l Corp." on Justia Law

Raybourne was a quality engineer for 23 years. The employer provided a long-term disability plan that paid benefits for up to 24 months if disability prevented him from performing the duties of his regular job. After 24 months, the plan paid benefits only if he was unable to perform all material duties of any occupation for which he was reasonably qualified. Raybourne suffered degenerative joint disease in his foot, with severe pain. In 2003, he stopped working and underwent the first of the four surgeries. From December 2003 through February 2006, Cigna paid benefits, then determined that he was not disabled under the more stringent standard. Raybourne exhausted administrative remedies, then sued under 29 U.S.C. 1132(a)(1)(B). The district court ruled in favor of Cigna. On remand the court rejected Cigna’s “unconvincing” explanation for how the company determined that Raybourne was not disabled. The court found that Cigna relied on the report of a non-treating physician and on the Social Security Administration’s initial rejections of Raybourne’s claim, failing to consider the SSA’s final determination of disability. The Seventh Circuit affirmed, finding that denial of benefits was based on a conflict of interest rather than on the facts and the terms of the policy. View "Raybourne v. CIGNA Life Ins. Co. of NY" on Justia Law

Decedent, father of plaintiffs, died without naming a beneficiary of his Unum life insurance. Plaintiffs sued Unum, asserting a breach of the policy and an Employee Retirement Income Security Act, 29 U.S.C. 1002 et seq., violation. The district court concluded that they lacked standing and dismissed the suit. The court concluded that the estate's decision not to appeal precluded the children from having a reasonable or colorable claim to benefits. Because plaintiffs could not become entitled to benefits, the court held that the district court properly dismissed the case. View "A.J., et al v. UNUM, et al" on Justia Law

In a 2009 opinion, the Sixth Circuit held that, in a 1998 collective bargaining agreement, CNH agreed to provide health-care benefits to retirees and their spouses for life, but rejected the suggestion that the scope of this commitment in the context of healthcare benefits, as opposed to pension benefits, meant that CNH could make no changes to the healthcare benefits provided to retirees. The court remanded for a determination of reasonableness with respect to CNH’s proposed changes to its retiree healthcare benefits, under which retirees, previously able to choose any doctor without suffering a financial penalty, would be put into a managed-care plan. The court listed three considerations: Does the modified plan provide benefits “reasonably commensurate” with the old plan? Are the proposed changes “reasonable in light of changes in health care”? And are the benefits “roughly consistent with the kinds of benefits provided to current employees”? On remand, the district court granted CNH summary judgment without reaching the reasonableness question or creating a factual record from which the determination could be made on appeal. The Sixth Circuit again remanded.View "Reese v. CNH America LLC" on Justia Law

Defendant Goding was a beneficiary of an Employee Retirement Insurance Security Act (ERISA), 29 U.S.C. 1001 et seq., Plan administered by Drury. Goding sustained injuries in a slip and fall accident and received benefits from the Drury-administered Plan, as well as compensation through the settlement of a civil suit related to those injuries. Pursuant to a subrogation provision in the ERISA Plan, Drury attempted to secure reimbursement from Goding for the benefits it paid but was unable to do so after Goding declared bankruptcy. Drury then attempted to obtain that reimbursement from the firm that represented Goding. The court affirmed the district court's finding that Drury could not obtain such reimbursement because the firm had not agreed to the Plan's subrogation provision and consequently was not contractually bound by it; Drury could not maintain a suit against the firm in equity and could not bring a state cause of action for conversion against the firm; and the firm should be awarded attorneys' fees for successful defense of a subsequent motion. View "Treasurer, Trustees of Drury Ind. v. Goding, et al." on Justia Law

Schorsch enrolled in a long-term disability plan in 1991, but apparently never received a summary plan description or explanation of the Employee Retirement Income Security Act, 29 U.S.C.1132. In 1992 she was in an automobile accident; in 1993 Schorsch began receiving disability benefits. In 2006, at the plan’s request, Schorsch underwent a medical exam, which resulted in a report finding her capable of performing a medium duty job. The plan notified Schorsch that it would terminate her benefits, but did not mention a surveillance report, which was part of the determination. , Schorsch’s counsel sent a letter, but neither Schorsch nor her attorney submitted a request for review. The plan notified Schorsch that the appeals period had passed. Schorsch’s claimed breach of contract and unreasonable denial of benefits under Illinois law and ERISA violations. The plan had lost the administrative record relating to Schorsch’s claim. The district court granted summary judgment on the ground of failure to exhaust administrative remedies. The Seventh Circuit affirmed. There are exceptions that may excuse a failure to exhaust, but Schorsch offered no evidence of reasonable reliance on information missing from the notice or that alleged deficiencies were material. View "Schorsch v. Reliance Standard Life Ins. Co." on Justia Law

Plaintiffs are retired unionized employees of defendant and were covered by collective bargaining agreements that addressed healthcare benefits. The parties contest whether the CBAs guaranteed employees and their spouses lifetime healthcare benefits after retirement. After retiring, the employees and spouses continued to receive healthcare insurance from defendant. Between ages 62 to 65, defendant paid 80% of the premium costs. When the retirees turned 65, defendant assumed 100% of premium costs. In 2006, defendant informed plaintiffs that the company was instituting a new healthcare plan that would no longer cover 100% of the premiums. Plaintiffs claimed violations of the Labor Management Relations Act, 29 U.S.C. 185, and the Employee Retirement Income Security Act, 29 U.S.C. 1132. The district court ruled in plaintiffs’ favor as to employee coverage, but in favor of defendant as to spouses. The Sixth Circuit reversed in part, in favor of plaintiffs. Although healthcare is a “welfare benefit,” not entitled to the same ERISA protection as pension benefits, employers are free to waive their power to alter welfare benefits. Defendant did so by offering vested healthcare coverage to retired employees and spouses, and by agreeing that CBAs could only be modified with signed, mutual consent of the parties. View "Moore v. Menasha Corp." on Justia Law

Eloise Walker, mother of the decedent, appealed the grant of summary judgment in favor of Pamela Wright-Dallas, the named beneficiary under the decedent's benefits plans. Walker argued that the district court erred because it made a ruling without first reviewing the entire administrative record, and in the alternative, the district court erred by applying the wrong standard of review. The court found no plain error and rejected Walker's claim that the district considered an inadequate record; the district court properly applied the abuse-of-discretion standard; and a heightened standard of review was not warranted. Accordingly, the court affirmed the judgment. View "Trustees of the Local No. 1, et al. v. Walker" on Justia Law