Justia ERISA Opinion Summaries

Dorris, a company president, had Unum long-term disability insurance. Her endometriosis became disabling; Unum started paying her benefits in 2002. Later, Dorris was diagnosed with Lyme disease. By 2007, the Social Security Administration granted her disability benefits. To maintain Unum benefits after two years, an employee had to prove that she “cannot perform each of the material duties of any gainful occupation for which [she is] reasonably fitted” or that she is “[p]erforming at least one of the material duties" of any occupation and “[c]urrently earning at least 20% less" due to the disability. In 2015, Dorris told Unum that she was improving and had started golfing and volunteering. Dorris’s Lyme disease specialist indicated that Dorris still had major symptoms and could not work. Unum’s consulting physicians found no evidence of limitations that would preclude sedentary work nor of an active Lyme infection. Unum ended her benefits.In her Employee Retirement Income Security Act (29 U.S.C. 1132(a)(1)(B)) lawsuit, Dorris was denied permission to depose witnesses to clarify the administrative record. Dorris never sought further discovery; nor objected to the ruling. Unum rested on its physician’s conclusions that Dorris could perform the duties of a president. Dorris asserted, without evidence, that such jobs required “55–70 hours a week,” and focused on how little she did as a volunteer. The court limited its review to the administrative record and found that Dorris could not perform the duties of her regular occupation, but nonetheless ruled in Unum's favor, because Dorris's arguments based on the "20% less" option were conclusory. The Seventh Circuit affirmed. The plaintiff bears the burden of proving that she is entitled to benefits. The court did not abuse its discretion in denying Dorris the opportunity to supplement the record after judgment nor were its factual findings in error. View "Dorris v. Unum Life Insurance Co. of America" on Justia Law

The First Circuit affirmed the judgment of the district court in favor of Sun Life Assurance Company of Canada finding that Sun Life properly permitted an offset of Appellant's benefits under tis employer-sponsored long-term disability insurance policy (the Plan) by the amount of Appellant's service-connection disability compensation (Veterans' Benefits), holding that the district court did not err.Specifically, the First Circuit held (1) Appellant's Veterans' Benefits fell squarely within the definition of "Compulsory Benefit Act or Law"; (2) that the district court did not err by concluding as a matter of law that Veterans' Benefits unambiguously qualify as a form of "Other Income Benefit" covered by the Plan's offset provision; and (3) the district court did not err by rejecting as a matter of law Appellant's assertion that Sun Life's offset determination was motivated, at least in part, by Appellant's military service in violation of the Uniformed Services Employment and Reemployment Rights Act. View "Martinez v. Sun Life Assurance Co. of Canada" on Justia Law

The Eighth Circuit affirmed the district court's dismissal of Air Evac's claims in an action alleging that Arkansas Blue inadequately reimbursed Air Evac for ambulance services that Air Evac provided Arkansas Blue plan members. The court held that Air Evac's assignment did not convey the right to sue for equitable relief under section 1132(a)(3) of the Employee Retirement Income Security Act (ERISA). Furthermore, the district court did not err by finding that Arkansas Blue's conduct was not actionable because it fell within the Arkansas Deceptive Practices Act's safe harbor for actions or transactions permitted under the laws administered by the insurance commissioner. Finally, the district court did not err by rejecting Air Evac's claims for breach of contract and unjust enrichment. View "Air Evac EMS, Inc. v. USAble Mutual Insurance Co." on Justia Law

Fessenden’s employment was terminated after he began receiving short-term disability benefits. He then applied for long‐term disability benefits through his former employer’s benefits plan. The plan administrator, Reliance, denied the claim. Fessenden submitted a request for review with additional evidence supporting his diagnosis of Chronic Fatigue Syndrome. When Reliance failed to issue a decision within the timeline mandated by regulations governing the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132, he filed suit. Eight days later, Reliance finally issued a decision, again denying Fessenden’s claim. The district court granted Reliance summary judgment. The Seventh Circuit vacated. If the decision had been timely, the court would have applied an arbitrary and capricious standard because the plan gave Reliance the discretion to administer it. When a plan administrator commits a procedural violation, however, it loses the benefit of deference and a de novo standard applies. The court rejected Reliance’s argument that it “substantially complied” with the deadline because it was only a little bit late. The “substantial compliance” exception does not apply to blown deadlines. An administrator may be able to “substantially comply” with other procedural requirements, but a deadline is a bright line. View "Fessenden v. Reliance Standard Life Insurance Co." on Justia Law

Lacko began working for BKD’s predecessor in 1999 and worked until September 2015, when she was Senior Manager in the Audit Department, with an annual salary of $93,250.04. She applied for benefits under the short term disability (STD) plan, claiming gastroparesis, diabetes, rheumatoid arthritis, congestive heart failure, breathing difficulties, anxiety, musculoskeletal impairments, and cognitive difficulties related to the medication needed to manage the other conditions. Although United approved her claims for STD benefits three times, it denied benefits in June 2016 for the period beyond November 22, 2015, concluding there was no change in Lacko’s medical condition when she stopped working or subsequently. United also denied her claim for long term disability benefits. Lacko sued under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001.. The district court granted United summary judgment. The Seventh Circuit reversed. United failed to adequately address a determination that Lacko was entitled to Social Security disability benefits and failed to recognize the significant distinction between her ability to perform unskilled work and the job of Senior Manager. The court noted that the Plan’s requirement of a “change” in a person’s physical or mental capacity in order to qualify for benefits does not by its terms preclude a degenerative condition from qualifying a claimant for benefits and noted United's conflict of interests, having issued the policies and serving as claims review fiduciary. View "Lacko v. United of Omaha Life Insurance Co." on Justia Law

Llenos hung a noose from a basement ceiling beam, stood on a stool with the noose around his neck, and stepped off. Llenos died as a result. When Tran came home, she found her husband’s body. Though his death was initially reported as suicide, the medical examiner concluded from sexual paraphernalia on Llenos’s body that he died performing autoerotic asphyxiation, a sexual practice by which a person purposefully restricts blood flow to the brain to induce a feeling of euphoria. Llenos was covered by basic and supplemental life insurance policies, providing $517,000 in coverage, and including Accidental Death & Dismemberment (AD&D) policy riders providing an additional $60,000 in coverage. Minnesota Life paid $517,000 but denied Tran’s claim for the additional $60,000 in AD&D coverage, concluding that Llenos’s death was not “accidental” and fell under an exclusion for intentionally self-inflicted injury. Tran filed suit under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(1)(B). The district court awarded Tran judgment, reasoning that the insurer had conceded the death was accidental. The Seventh Circuit reversed, finding that autoerotic asphyxiation was the ultimate and the proximate cause of Llenos’s death. Strangling oneself to cut off oxygen to one’s brain is an injury. When that injury kills, it is “an intentionally self-inflicted injury which resulted in death,” regardless of whether it was done recreationally or with an intent to survive. View "Tran v. Minnesota Life Insurance Co." on Justia Law

The Fifth Circuit affirmed the district court's judgment in favor of Principal in an action brought by plaintiff, alleging that Principal abused its discretion by denying her benefits. The court held that Principal's benefits denial was supported by substantial evidence. The court held that, at bottom, there was no abuse of discretion in Principal's reliance on its own treating physicians' reports detailing an absence of plaintiff's impairments. The court also held that, although Principal had a structural conflict of interest that it both evaluates and pays claims, this factor had little weight in light of the extensive investigation that Principal conducted. View "Foster v. Principal Life Insurance Co." on Justia Law

Dr. Griffin provided medical care to T.R., a participant in a Central States health plan. Before receiving treatment, T.R. assigned to Griffin the rights to “pursue claims for benefits, statutory penalties, [and] breach of fiduciary duty ….” Griffin confirmed through a Central representative that the plan would pay for the treatment at the usual, reasonable, and customary rate, then treated T.R. and submitted a claim for $7,963. Griffin later challenged the benefits determination, requesting a copy of the summary plan description and documents used to determine her payment. Six months later, Central responded that iSight, a third party, used “pricing methodology” to determine the fee and telling her to negotiate with iSight before engaging in the appeals process that the plan required before a civil suit. Griffin missed a call from iSight, returned the call, and left a message that she “would not take any reductions.” iSight never called back. Central provided a copy of the summary plan description, but no fee schedules or tables. Griffin sued under ERISA, 29 U.S.C. 1132(a)(1)(B), (a)(3), alleging that Central did not pay her the proper rate under the plan; breached its fiduciary duty by not adhering to plan terms; and failed to produce, within 30 days, the summary plan description she requested, nor iSight’s fee schedules. The court dismissed. The Seventh Circuit affirmed in part and vacated in part. Griffin adequately alleged that she is eligible for additional benefits and statutory damages. View "Griffin v. Teamcare" on Justia Law

Hennen worked as a sales specialist for NCR, 2010-2012, and was covered by long-term disability insurance under a group policy provided by MetLife. She sought treatment for a back injury. When physical therapy and surgery failed to resolve her injury, Hennen applied for long-term disability benefits. Acting as plan administrator, MetLife agreed that Hennen was disabled and paid benefits for two years. The plan has a two-year limit for neuromusculoskeletal disorders, subject to exceptions, including on for radiculopathy, a “Disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.” After MetLife terminated Hennen’s benefits, she sued under the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001 (ERISA), arguing that MetLife’s determination that she did not have radiculopathy was arbitrary and capricious. The district court granted MetLife summary judgment. The Seventh Circuit reversed. MetLife acted arbitrarily when it discounted the opinions of four doctors who diagnosed Hennen with radiculopathy in favor of the opinion of one physician who ultimately disagreed, but only while recommending additional testing that MetLife declined to pursue. View "Hennen v. Metropolitan Life Insurance Co." on Justia Law

Springer, a Utah physician, began a fellowship at the Cleveland Clinic and enrolled his family in its employee benefit plan, administered by Antares. During the enrollment period, Springer had his 14-month-old son, J.S., transported from a Utah hospital to the Cleveland Clinic by Angel Jet’s air ambulance service. J.S. had been hospitalized since birth for multiple congenital abnormalities. He required a mechanical ventilator. J.S.’s physician prepared a letter of medical necessity for the service. Before the flight, Angel Jet contacted Antares, which was unable to confirm that Springer and his son were members of the plan and did not precertify the service. Angel Jet proceeded with the transportation and submitted a bill to Antares for $340,100. Antares denied it for failure to obtain precertification. The Plan affirmed the denial but paid $34,451.75, reflecting the amount their preferred provider would have charged. Angel Jet brought suit under the Employee Retirement Security Act. The district court dismissed the suit, finding that Springer had not properly assigned his rights under the plan to Angel Jet. Springer then brought his own claim under ERISA Section 502(a)(1)(B). The Sixth Circuit affirmed, first finding that Springer had standing despite having received the service and not being billed. The denial was not arbitrary and capricious because J.S.’s transportation was not an emergency or precertified as required for a nonemergency. View "Springer v. Cleveland Clinic Employee Health Plan Total Care" on Justia Law