Justia ERISA Opinion Summaries

Plaintiff sought accidental death benefits under an employee benefit plan governed by the Employee Retirement Income and Security Act of 1974 (ERISA) after his wife died from injecting herself with a cocktail of unprescribed narcotics. The district court upheld the Life Insurance Company of North America’s (LINA) decision to deny benefits based on a policy exclusion for the “voluntary ingestion of any narcotic, drug, poison, gas or fumes unless prescribed or taken under the direction of a Physician.” Plaintiff appealed, contending that the district court erred because LINA’s decision was unreasonable and not supported by substantial evidence.   The Eighth Circuit affirmed. The court decided that LINA’s interpretation of “ingestion” was reasonable. The court then turned to whether LINA’s application of its interpretation to the facts is supported by substantial evidence. Here, the wife undisputedly died because she willingly injected herself with a combination of unprescribed narcotics. Therefore, there is sufficient evidence to support LINA’s application of the voluntary ingestion exclusion to the wife’s death. Thus, because the court agreed with the district court’s conclusion that LINA’s denial of benefits was justified in light of the voluntary ingestion exclusion, the court wrote it need not address LINA’s assertion that the wife’s death was not accidental. View "Jay Richmond v. Life Insurance Company" on Justia Law

Principal Life Insurance Company (Principal) offers a product called the Principal Fixed Income Option (PFIO), a stable value contract, to employer-sponsored 401(k) plans. Plaintiff on behalf of himself and a class of plan participants who deposited money into the PFIO, sued Principal under the Employee Retirement Income Security Act of 1974 (ERISA), claiming that it (1) breached its fiduciary duty of loyalty by setting a low-interest rate for participants and (2) engaged in a prohibited transaction by using the PFIO contract to make money for itself. The district court granted summary judgment to Principal after concluding that it was not a fiduciary. The Eighth Circuit reversed, holding that Principal was a fiduciary. On remand, the district court entered judgment in favor of Principal on both claims after a bench trial. Plaintiff challenges the court’s judgment.   The Eighth Circuit affirmed. The court agreed with the district court that Principal and the participants share an interest because a guaranteed CCR that is too high threatens the long-term sustainability of the guarantees of the PFIO, which is detrimental to the interest of the participants. The question then becomes whether the court clearly erred by finding that Principal set the CCR in the participants’ interests. The court held that the district court did not clearly err by finding that the deducts were reasonable and set by Principal in the participants’ interest of paying a reasonable amount for the PFIO’s administration.  Finally, the court affirmed the district court’s judgment in favor of Principal on the prohibited transaction claim because it is exempted from liability for receiving reasonable compensation. View "Frederick Rozo v. Principal Life Insurance Co." on Justia Law

Plaintiff's son died in a single-vehicle collision. At the time, he was intoxicated and driving the wrong way on a one-way road. The accidental death and dismemberment insurance policy obtained from defendant Life Insurance Company of North America (LINA) by the plaintiff via his employer paid benefits for a “Covered Accident,” defined as “[a] sudden, unforeseeable, external event that results, directly and independently of all other causes.”Applying the Padfield test, Padfield v. AIG Life Ins. Co., 290 F.3d 1121 (9th Cir. 2002), the son’s death was an “accident” because, while the facts demonstrated that the son engaged in reckless conduct, the record did not show that his death was “substantially certain” to result from that conduct. Thus, the Ninth Circuit affirmed the district court's finding. View "SCOTT WOLF V. INS. CO. OF N. AMERICA" on Justia Law

The First Circuit affirmed the judgment of the district court in favor of an employee's widow in this insurance dispute, holding that the employee did not lose life insurance coverage under his employer's group policy after he developed a brain tumor that disrupted his usual work.Plaintiff, the employee's widow, submitted a statement to Insurer claiming approximately $1 under her late husband's life insurance policy. Insurer denied the claim. Plaintiff then sued, alleging wrongful denial of benefits under section 502(a) of ERISA, 29 U.S.C. 1132(a)(1)(B), (a)(3). The insurance company denied life insurance coverage on the grounds that the employee's coverage under the policy had lapsed. The district court granted summary judgment for Plaintiff. The First Circuit affirmed, holding (1) because the policy language invoked by Insurer in this case was less than clear the rule that ambiguous terms in an insurance policy should be read in favor of coverage applied; and (2) the employee was covered at the time of his demise. View "Ministeri v. Reliance Standard Life Insurance Co." on Justia Law

Tymoc died in a single-car accident. At the time of the accident, Tymoc was traveling between 80-100 miles per hour; the speed limit was 60 miles per hour speed. As Tymoc attempted to pass multiple cars, the gap between a car in the right lane and a box truck in the left lane closed. Tymoc veered to the right, causing his vehicle to drive off the road, roll down an embankment, striking multiple trees, and flip over several times.Through his employer, Tymoc was covered by Unum life insurance; the policy provided both basic life insurance coverage and an additional accidental death benefit. Unum approved a $100,000 payment of group life insurance benefits but withheld $100,000 in accidental death benefits, explaining that Tymoc’s conduct—speeding and reckless driving—caused his death, thereby triggering the policy’s crime exclusion. In a suit under the Employee Retirement Income Security Act, 29 U.S.C. 1001– 1191d, the district court entered in Fulkerson’s favor as to the accidental death benefits. The Sixth Circuit reversed. Reckless driving falls within the unambiguous plain meaning of crime. View "Fulkerson v. Unum Life Insurance Co. of America" on Justia Law

Canter worked as a premises technician, installing wires, lifting heavy loads, and climbing tall ladders. After he began to suffer from severe migraines, lightheadedness, and dizziness, Canter concluded that he no longer could perform that work. He applied for short-term disability benefits in February 2017 through an AT&T plan. The plan administrator granted benefits for a few months, but AT&T terminated benefits after an independent medical reviewer concluded that Canter’s medical tests were normal and that his symptoms had improved. After Canter unsuccessfully appealed this decision using AT&T’s internal processes, he sued under the Employment Retirement Income Security Act (ERISA), 29 U.S.C. 1132.The district court granted the defendants summary judgment in favor of the defendants. The Seventh Circuit affirmed the decision but reversed the court’s award of $181 in pro hac vice fees to the defendants as not taxable “costs” under 28 U.S.C. 1920. Extensive medical testing consistently yielded normal results, even though the medical providers and reviewers thought that a significant problem would have shown up in one or more concrete, physiological ways. Canter himself reported that he was experiencing improvement. View "Canter v. AT&T Umbrella Benefit Plan No.3" on Justia Law

Plaintiff sued Defendant insurance company for mishandling his wife’s enrollment for supplemental life insurance and then declaring her ineligible for coverage after she died. The district court determined Defendant violated ERISA, finding Defendant breached its fiduciary duty to ensure its system of administration did not allow it to collect premiums until coverage was actually effective. Defendant appealed.The Eighth Circuit affirmed. Defendant maintained its fiduciary duty despite the fact that the deceased's employer collected premium payments before forwarding them to Defendant. The plan in question gave Defendant discretion to approve benefits, which under ERISA is sufficient to create a fiduciary duty. Defendant violated its fiduciary duty by failing to maintain an effective enrollment system. Under ERISA, a fiduciary must discharge its duties with reasonable care, skill, prudence and diligence. The court held that a reasonably prudent insurer would use a system that avoids the employer and insurer having different lists of eligible, enrolled participants. Defendant's billing system breached the fiduciary duty it owed to the deceased. Thus, the court affirmed the district court's granting of summary judgment to Plaintiff. View "Corey Skelton v. Reliance Standard Life Ins Co" on Justia Law

After more than a decade of employment, a seizure disorder ended Dr. Autran’s career as a P&G research scientist. Autran received total-disability benefits under P&G’s Health and Long-Term Disability Plan in 2012-2018. The Committee terminated those benefits after concluding that Autran no longer qualified as totally disabled within the meaning of the Plan, and awarded him his remaining 19 weeks of partial disability benefits. Autran sued under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(1)(B). He died while the suit was pending.The Sixth Circuit upheld summary judgment in favor of the Committee. Because the Plan delegates discretionary authority to the Committee to decide benefits claims, the court applied the deferential arbitrary-and-capricious test. The Committee had rational reasons to depart from the earlier total-disability finding. Among other new evidence, a doctor who performed many objective tests on Autran for over six hours found no basis to conclude that he suffered from a debilitating condition. Thorough medical opinions gave the Committee a firm foundation to conclude that Autran did not, in the Plan’s words, suffer from a “mental or physical condition” that the “medical profession” would consider “totally disabling.” View "Autran v. P&G Health & Long Term Disability Benefit Plan" on Justia Law

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