Justia ERISA Opinion Summaries

Marantz practiced pulmonary and critical care medicine. In 1997 she underwent surgery for a herniated disc and degenerative disc disease. The surgery did not eliminate her pain. In 1999, she stopped working full time. Through her employment with she received disability coverage from LINA. LINA approved her claim. Additional surgery did not resolve the problem. MRIs revealed degenerative disc disease and spinal stenosis. In 2000 LINA provided funding for Marantz to enroll in an online Masters of Public Health program, for retraining for less-demanding work. In 2001, Marantz began working approximately 20 hours per week for the Illinois Department of Public Health. LINA offset disability benefits and reduced its monthly payment from $7,616 to $5,000 per month. LINA paid benefits for 60 months. In 2004, LINA investigated whether Marantz satisfied the policy’s more stringent definition of disability relevant after the first 60 months: “unable to perform all the material duties of any occupation for which [that worker] may reasonably become qualified based on education, training or experience.” In 2005 LINA terminated benefits, based on a functional capacity evaluation, doctors’ assessments, and surveillance. Marantz sued under the ERISA, 29 U.S.C. 113. The district court entered judgment in the defendants’ favor. The Seventh Circuit affirmed. View "Marantz v. Permanente Med. Grp., Inc." on Justia Law

Plaintiff appealed the district court's dismissal of her claim challenging the termination of her long-term disability benefits under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1132. Plaintiff challenged the district court's grant of summary judgment in favor of Unum on it's counterclaim for restitution of overpaid benefits. The court held that the district court abused its discretion by dismissing the claim for denial of benefits for failure to exhaust administrative remedies. The exhaustion requirement should have been excused because plaintiff acted reasonably in light of Unum's ambiguous communications and failure to engage in a meaningful dialogue. Accordingly, the court vacated the judgment in favor of Unum on plaintiff's claim for denial of benefits. View "Bilyeu v. Morgan Stanley Long Term Disability Plan, et al." on Justia Law

Defendant appealed the district court's grant of partial summary judgment in favor of CGI in its action seeking "appropriate equitable relief" under section 502(a)(3) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq. CGI appealed the district court's grant of partial summary judgment in favor of defendant's counsel and codefendant, dismissing the codefendant from the action. CGI also appealed the district court's grant of proportional fees and costs to the codefendant, deducted from CGI's recovery from defendant. The court affirmed the district court's grant of summary judgment in favor of the codefendant, dismissing it from the action. However, because the court saw no indication that in fashioning "appropriate equitable relief" for CGI, the district court did more than interpret the plain terms of the reimbursement provision, and no indication that the district court considered traditional equitable principles in assigning responsibility to CGI for attorneys' fees and costs, the court vacated the judgment in favor of CGI, vacated the judgment that the codefendant deducted fees and costs from CGI's entitlement, and remanded to the district court for further proceedings. View "CGI Technologies and Solutions v. Rose, et al." on Justia Law

LINA appealed the decision of the district court holding that it abused its discretion in its denial of benefits to plaintiff under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. Plaintiff alleged that LINA wrongly denied her the benefits of her common-law husband's ERISA-governed Group Accident Policies where her husband participated in two accidental death and dismemberment policies. The court affirmed the district court's holding that the common law definition of "accident" adopted in Todd v. AIG Life Insurance Co., was controlling in all ERISA accidental death and dismemberment plans where the term "accident" was undefined, irrespective of whether the plan administrator was given discretion to interpret the plan. View " Firman v. Beacon Construction Co., Inc." on Justia Law

Plaintiff appealed the district court's summary judgment dismissing her suit to recover health insurance benefits under an employee plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001-1461. Aetna, a Texas health maintenance organization (HMO), provided and administered the plan's health insurance benefits under an agreement giving Aetna discretion to interpret the plan's terms. Aetna refused to reimburse plaintiff for care she received from a specialist outside of the Aetna HMO to whom she had been referred by a physician in the HMO. Aetna denied her claim because the referral was not pre-authorized by Aetna. The district court found as a matter of law that Aetna did not abuse its discretion in denying coverage. The court found, however, that the plan was ambiguous and the need for pre-authorization was not clearly stated in Aetna's summary description of the plan. And under the circumstances of the case, it could not be said as a matter of law that Aetna did not abuse its discretion in denying coverage. View "Koehler v. Aetna Health, Inc." on Justia Law

The district court overturned an employee benefit plan's denial of a former employee's claim for permanent and total disability life insurance benefits. On appeal, Defendant Owens-Illinois Hourly Employees Welfare Benefit Plan contended the district court erred in rejecting Defendant’s argument that the employee was not eligible for this benefit under the Plan’s life insurance coverage provisions because his PTD life insurance claim was not filed until after he retired. Upon review, the Tenth Circuit concluded that the district court should have entered judgment in favor of Plaintiff on the administrative record rather than remanding for further administrative proceedings. The Tenth Circuit therefore remanded the case with directions for the district court to modify its order and enter judgment in favor of Plaintiff. View "Spradley v. Owens-Illinois Hourly Employees Welfare Benefit Plan" on Justia Law

LINA appealed the district court's ruling that LINA abused its discretion in denying death benefits to Dawn McClelland based upon her husband's life insurance policy. LINA also appealed the district court's award of attorney's fees. The court found that LINA committed an abuse of discretion in denying benefits because its interpretation was contrary to the language of the plan that it would cover "loss of life" based upon an "accident" and because substantial evidence did not support its decision. The court also found that the total fee awarded should be $85,000 and remanded to the district court to enter an award in that amount. The prejudgment interest award was affirmed. View "McClelland v. Life Ins. Co. of North America" on Justia Law

Plaintiffs, employees at a defense plant in Arizona, collectively bargained for the right to receive employer-provided healthcare coverage after they retired. At issue was whether those employees, now retirees, were contractually entitled to receive premium-free healthcare coverage until age 65, or whether the contracts on which the retirees relied as providing that entitlement allowed their prior employer to start charging them for their insurance. The court held that Raytheon expressly agreed to provide 100% company-paid healthcare coverage for eligible retirees; that Raytheon's obligation survived the expectation of the collective bargaining agreements (CBAs); and that Raytheon's agreed-upon obligation could not be unilaterally abrogated by Raytheon, regardless of the rights Raytheon reserved for itself in Plan documents, because the CBAs did not incorporate the Plans' reservation-of-rights provisions with respect to employer contribution issues, as opposed to issues relating to the provision of monetary or in kind benefits for particular medical services. The court further held that the district court did not err in rejecting plaintiffs' claim for punitive and extra-contractual damages. View "Alday, et al. v. Raytheon Co.; Agraves, et al. v. Raytheon Co." on Justia Law

While working as a dentist, Fleisher obtained long-term disability insurance coverage under separate policies. He obtained the North American policy by membership in a professional organization. The Standard policy is an employee benefit, governed by the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B) and provides for monthly benefits to a maximum of "$10,000 before reduction by Deductible Income," defined to include "[a]ny amount you receive or are eligible to receive because of your disability under another group insurance coverage," but to exclude benefits paid under "any individual disability insurance policy." In 2008, Fleisher became disabled and claimed benefits under both policies. Shortly after Fleisher began collecting under both policies, Standard reduced his monthly benefits from $10,000 to $8,500 based on its determination that the North American policy was another group insurance coverage, and that the $1,500 in benefits he receives under it is deductible income. The district court dismissed his ERISA suit. The Third Circuit affirmed, finding the decision supported by substantial evidence and not unreasonable. View "Fleisher v. Std. Ins. Co." on Justia Law

After plaintiff was denied long-term disability benefits by Standard, he sought review of Standard's determination under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq. The court affirmed the district court's grant of summary judgment in favor of Standard and held that there was substantial evidence supporting Standard's denial of benefits. The court also held that a conflict of interest alone was not determinative where there existed substantial evidence on the record supporting the denial of benefits. View "Hankins v. Standard Ins. Co." on Justia Law