Justia ERISA Opinion SummariesArticles Posted in U.S. 5th Circuit Court of Appeals
Koehler v. Aetna Health, Inc.
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
Stoffels, et al. v. SBC Communications, Inc., et al.
Plaintiffs brought an enforcement suit against defendants under the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001-1461. Plaintiffs alleged that defendants' practice of offering reimbursements for telephone services to retirees who lived outside of defendants' service region constituted a "pension plan" under ERISA. Judge Rodriquez was assigned to the claims at issue here and to Boos v. AT&T, a case involving similar claims. After ruling that the concession at issue in Boos was not a pension plan under ERISA, Judge Rodriquez reconsidered Judge Justice's interlocutory order with respect to plaintiffs' claims in this case. He concluded that the program of retirement benefits was not a pension plan under ERISA and he then entered a final judgment. Because the court concluded that Judge Rodriquez did not abuse his discretion by revising Judge Justice's interlocutory order, the court affirmed the judgment of the district court. View "Stoffels, et al. v. SBC Communications, Inc., et al." on Justia Law
ACS Recovery Services, Inc., et al. v. Griffin, et al.
ACS and FKI appealed the district court's decision to dismiss their suit for equitable relief under section 502(a)(3) of the Employee Retirement Income and Security Act of 1974 (ERISA), 29 U.S.C. 1132(a)(3)(B), for lack of jurisdiction. ACS and FKI argued that the district court: (1) erroneously interpreted two Supreme Court cases as requiring dismissal of their claims; (2) abused its discretion in denying their motion for a default judgment against one of the defendants; (3) should have concluded that Chapter 142 of the Texas Property Code was preempted by ERISA; and (4) should have deferred to the FKI Plan administrator's determination of liability. Pursuant to the three-part test in Bombardier Aerospace Emp. Welfare Benefit Plan v. Ferrer, Poirot, & Wansbrough, the court affirmed the district court's decision to dismiss the ERISA claims against Larry Griffin, Judith Griffith, Willie Earl Griffin (the Trustee), and the Larry Griffin Special Needs Trust for lack of jurisdiction. Accordingly, the court found it unnecessary to address the remaining arguments. View "ACS Recovery Services, Inc., et al. v. Griffin, et al." on Justia Law
Ballew, et al. v. Continental Airlines, Inc., et al.
This appeal arose from the district court's order dismissing plaintiffs' claim for lack of subject matter jurisdiction due to the Railway Labor Act's (RLA), 45 U.S.C. 151, 181, exclusive and mandatory dispute resolution process that applied to plaintiffs' claims. Plaintiffs argue that the RLA did not apply to them because they were no longer "employees" as contemplated by the RLA. Alternatively, plaintiffs argued that even if the RLA applied to them as former employees, they complied with the terms of their Collective Bargaining Agreement (CBA), which allowed them to bring an action in federal district court pursuant to section 501(a)(1)(B) of the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. The court held that plaintiffs were employees under the RLA pursuant to Supreme Court precedent. In the alternative, plaintiffs were explicitly looking for a "contracted-for" judicial remedy following an adverse RLA-established Retirement Board ruling without showing any of the narrow exceptions to RLA exclusivity. Therefore, the court declined to depart from established precedent preventing parties from creating federal court jurisdiction where there was none. Accordingly, the judgment was affirmed. View "Ballew, et al. v. Continental Airlines, Inc., et al." on Justia Law
Access Mediquip, L.L.C. v. UnitedHealthCare Ins. Co.
Plaintiff's lawsuit arose from defendant's refusal to pay some or all of plaintiff's claims for reimbursement for medical-device procurement and financing services provided in connection with over 2,000 patients insured under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., plans administered by defendant. Plaintiff subsequently appealed a summary judgment for defendant. At issue was whether plaintiff's state-law claims of promissory estoppel, quantum meruit, unjust enrichment, negligent misrepresentation, and violations of the Texas Insurance Code, 541.051(A) & (B) and 541.061(1) & (2), were preempted by ERISA. The court reversed with respect to plaintiff's promissory estoppel, negligent misrepresentation, and Texas Insurance Code claims because these claims were premised on allegations and evidence that plaintiff provided the services in reliance on defendant's representations that it would pay reasonable charges for plaintiff's services. The court affirmed with respect to plaintiff's quantum meruit and unjust enrichment claims because these claims depended on plaintiff's assertion that without its services the patients' ERISA plans would have obligated defendant to reimburse a different provider for the same services. View "Access Mediquip, L.L.C. v. UnitedHealthCare Ins. Co." on Justia Law
Evans, et al. v. Sterling Chemicals, Inc., et al.
This appeal required the court to determine what effect, if any, a retiree benefits-related provision included in an asset purchase agreement had on the acquiring company's retiree benefits plans governed under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1000 et seq. The court held that the provision constituted a valid plan amendment. Moreover, the court held that the provision was assumed, not rejected, in bankruptcy. Accordingly, the court reversed and remanded. View "Evans, et al. v. Sterling Chemicals, Inc., et al." on Justia Law
Kujanek v. Houston Poly Bag I, Ltd.
Plaintiff sued his former employer under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001, et seq., to recover profit sharing and retirement benefits that were allegedly withheld from him. The district court granted summary judgment for plaintiff on his claims that the employer breached its fiduciary duty of loyalty and violated ERISA's disclosure requirements. The district court also awarded plaintiff statutory penalties and attorney's fees. The court affirmed the district court's award of damages for breach of fiduciary duty and attorney's fees. The court held, however, that the summary allocation report contained no information about how a participant could elect to receive a rollover distribution, nor did it inform the participant of her rights under the profit-sharing plan. Therefore, the court remanded to the district court for additional findings on whether the employer failed to furnish plaintiff with the requisite documents under ERISA 104(b)(1), and if so, whether that omission served as a basis for statutory penalties. View "Kujanek v. Houston Poly Bag I, Ltd." on Justia Law
Crosby v. Louisiana Health Serv.
Appellant appealed the district court's summary judgment on her ERISA, 29 U.S.C. 1132(a)(1)(B), claim to recover denied health care benefits and the magistrate judge's decision to limit discovery. At issue was the scope of admissible evidence and permissible discovery in an ERISA action to recover benefits under section 1132(a)(1)(B). The court held that the district court too narrowly defined the scope of discovery where appellant sought to discover evidence that would indicate whether the administrative record was complete, whether Blue Cross complied with ERISA's procedural requirements, and whether Blue Cross previously afforded coverage claims related to the jaw, teeth, or mouth. The court concluded that appellant's discovery request was at least reasonably calculated to lead to the discovery of some admissible evidence and that the district court's abuse of discretion prejudiced appellant's ability to demonstrate that Blue Cross failed to comply with ERISA's procedural requirements. Accordingly, the court vacated and remanded for further proceedings. View "Crosby v. Louisiana Health Serv." on Justia Law
Brown, et al v. Continental Airlines, Inc., et al.
Appellants filed suit against nine pilots and their spouses asserting claims for equitable relief under 29 U.S.C. 1132(a)(3) of ERISA where appellants alleged that the pilots and their spouses obtained "sham" divorces for the purpose of obtaining lump sum pension distributions from the Continental Pilots Retirement Plan. At issue was whether ERISA, 29 U.S.C. 1056(d)(1), allowed a retirement plan administrator to seek restitution of benefits that were paid to a plan participant's ex-spouse pursuant to a domestic relations order such as a divorce decree, if the administrator subsequently determined that the domestic relations order was based on a "sham" divorce. The court agreed with the district court's holding that subsection 1056(d)(3)(D)(i) did not authorize an administrator to consider or investigate the subjective intentions or good faith underlying a divorce. Therefore, the court affirmed the district court's dismissal of appellants' claims. View "Brown, et al v. Continental Airlines, Inc., et al." on Justia Law
Boos, et al. v. AT&T, Inc., et al.
Plaintiffs brought an enforcement suit against defendants under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. 1001-1461. At issue was whether the district court properly granted summary judgment in favor of defendants, concluding that defendants' practice of offering discounted telephone services to employees and retirees ("Concession") was not a pension plan in whole or in part. The court affirmed summary judgment and held that the district court did not err in holding that Concession was one plan, at least as it regarded to all retirees; in refusing to examine the out-of-region retiree Concession in isolation; in concluding that although Concession did provide income to some retirees, such income was incidental to the benefit, and was not designed for the purpose of paying retirement income; and in holding that Concession did not result in a deferral of income. View "Boos, et al. v. AT&T, Inc., et al." on Justia Law