Justia ERISA Opinion Summaries

After the decedent died, Plaintiff, his surviving spouse, filed suit seeking relief under a provision of the Employee Retirement Income Security Act allowing “a participant or beneficiary” of an employee benefit plan “to recover benefits due” “under the terms of [the] plan.” The parties submitted a joint stipulation of facts and an administrative record and cross-moved for judgment based on those undisputed materials. The district court entered judgment for Prudential. The court concluded Prudential “reasonably denied Plaintiff’s request for benefits” because “decedent received timely notice of his conversion rights” and “did not convert his life insurance to an individual policy during the conversion period.” The district court also rejected Plaintiff’s request to “apply the doctrine of equitable tolling and find that Plaintiff is entitled to the life insurance benefits she seeks.”   The Fourth Circuit affirmed. The court wrote that it agreed with the district court that the plan administrator did not abuse its discretion in concluding Plaintiff was not entitled to benefits under the terms of the plan. The court explained that “Employers have large leeway to design [employee benefit] plans as they see fit,” but “once a plan is established, the administrator’s duty is to see that the plan is maintained pursuant to that written instrument.” Here, Prudential did not abuse its discretion by fulfilling its duty here, and the district court correctly resolved the single claim before it based on the agreed-on facts and consistent with well-established law. View "Kathy Hayes v. Prudential Insurance Company of America" on Justia Law

Plaintiff sued Minnesota Life Insurance Company and Securian Life Insurance Company, alleging that their denial of her claim for life insurance benefits violated the Employee Retirement Income Security Act (“ERISA”). The district court dismissed her complaint under the Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim.   The Eighth Circuit affirmed. The court concluded that the district court properly dismissed Plaintiff’s Section 1132(a)(3) claim. First, her contention that Minnesota Life and Securian failed to notify her husband of his conversion right does not amount to a breach of fiduciary duty because the terms of her husband’s policy did not require notice, and Plaintiff points to no provision of ERISA that would require such notice. Second, her assertion that Minnesota Life and Securian misrepresented that her husband’s conversion window would be extended rests on a misreading of the February 24 letter; Minnesota Life and Securian made no such representation. View "Kristina Powell v. Minnesota Life Insurance Co." on Justia Law

After her husband died of a heroin overdose, Plaintiff sought accidental death benefits under an employer-sponsored benefit plan governed by the Employee Retirement Income Security Act of 1974 (ERISA). The plan’s insurer, Symetra Life Insurance Company, denied her claim, and Plaintiff sued. The district court granted summary judgment in Plaintiff’s favor. Symetra appealed, arguing that Plaintiff’s suit is barred by her failure to exhaust internal review procedures and that her husband’s death otherwise falls under an exclusion to coverage.   The Eighth Circuit affirmed. Symetra contends that the exclusion applies to Plaintiff’s husband’s death because he “purposely” used heroin. But just because the act of using an illegal substance is purposeful does not mean that an injury stemming from that act, including a fatal overdose, was too. Symetra also maintains that Plaintiff’s husband, as a “longtime drug user,” was surely aware of the risks of using heroin and that his “generalized knowledge” of such risks is sufficient for his death to fall under the “intentionally self-inflicted injury” exclusion. The court reasoned that even assuming Symetra’s characterization of Plaintiff’s husband’s drug use is accurate, the argument attempts to replace an exclusion that applies only to “intentionally self-inflicted” injuries with one that also includes injuries resulting from reckless, or even negligent, conduct. The court wrote that the plain language of Symetra’s “intentionally self-inflicted injury” exclusion does not apply to unintended injuries like Plaintiff’s husband’s heroin overdose. Thus, Symetra’s denial of Plaintiff’s claim for accidental death benefits based on that exclusion was erroneous. View "Terri Yates v. Symetra Life Insurance Company" on Justia Law

Appellant American Federation of State, County and Municipal Employees, Council 3 (“Appellant”) filed suit against the State of Maryland alleging that the State breached a statutorily formed contract with current state employees to provide them with certain prescription drug benefits upon retirement. The district court agreed that Maryland law created a contract, it held that the contract was unilateral in nature and that the promised benefits do not vest until an employee retires with sufficient years of service. The district court determined that the current employees represented by Appellant had no vested contractual right to the retirement prescription drug benefits and dismissed the complaint.   The Fourth Circuit affirmed. However, the court did so because it found that the statutory language does not create a contract with state employees. The court explained that in reviewing the language of the statutes at issue, it concluded that they do not create a contract binding upon the State. While Section 2-508 does “entitle” retirees to a subsidy, it does not include any unmistakable contract language. Rather, it only “entitles” a retiree to the “same State subsidy allowed a State employee.” The court explained that nothing in Sections 2-508 or 2-509.1 leaves the court with an unmistakably “clear indication that the legislature intended to bind itself contractually.” Therefore, “all doubts must be resolved in favor of the continuance of the power” of the state legislature to modify or repeal enactments of a previous legislature. View "AFSCME Maryland Council 3 v. State of Maryland" on Justia Law

Plaintiffs-Appellees, emergency care physician groups in Texas (the “Plaintiff Doctors”), have provided various emergency medical services to patients enrolled in health insurance plans insured by Defendants-Appellants UnitedHealthcare Insurance Company or UnitedHealthcare of Texas, Incorporated (collectively, “UHC”). The Plaintiff Doctors are not within UHC’s provider network. In their operative complaint, the Plaintiff Doctors allege (among other claims) that UHC has failed to remit the “usual and customary rate” for the emergency care that the Plaintiff Doctors provide to patients insured by UHC in violation of the Emergency Care Statutes. UHC moved to dismiss the Plaintiff Doctors’ complaint, which was denied in part by the district court. The district court rejected UHC’s argument that the Emergency Care Statutes did not authorize a private cause of action. UHC immediately sought interlocutory review of two issues: (1) whether the Emergency Care Statutes authorize an implied private cause of action, and (2) whether the Plaintiff Doctors’ claim under the Emergency Care Statutes is otherwise preempted by ERISA.   The Texas Supreme Court answered the certified question in the negative, holding that the Texas Insurance Code “does not create a private cause of action for claims under the Emergency Care Statutes.” Therefore, the Fifth Circuit found that the Plaintiff Doctors’ claim for violation of the Emergency Care Statutes must be dismissed. Because there is no private cause of action under the Emergency Care Statutes, the second issue before the court—whether the Plaintiff Doctors’ claim under the Emergency Care Statutes is otherwise preempted by ERISA—is now moot. View "ACS Primary v. UnitedHealthcare" on Justia Law

Plaintiff Robert Harrison, a participant in a defined contribution retirement plan established by his former employer, filed suit under the Employee Retirement Income Security Act (ERISA) against the fiduciaries of the plan alleging that they breached their duties towards, and caused damages to, the plan. Harrison sought various forms of relief, including a declaration that Defendants breached their fiduciary duties, the removal of the current plan trustee, the appointment of a new fiduciary to manage the plan, an order directing the current trustee to restore all losses to the plan that resulted from the fiduciary breaches, and an order directing Defendants to disgorge the profits they obtained from their fiduciary breaches. Defendants moved to compel arbitration, citing a provision of the plan document. The district court denied that motion, concluding that enforcing the arbitration provision of the plan would prevent Harrison from effectively vindicating the statutory remedies sought in his complaint. The Tenth Circuit Court of Appeals found no reversible error in the district court’s ruling and affirmed. View "Harrison v. Envision Management Holding, Inc. Board, et al." on Justia Law

Plaintiffs submitted health plan coverage requests, which United Behavioral Health (“UBH”) denied. Plaintiffs brought claims under ERISA for breach of fiduciary duty and improper denial of benefits. The parties stipulated to a sample class, from which they submitted a sample of health insurance plans. Plaintiffs alleged that the plans provided coverage for treatment consistent with generally accepted standards of case (“GASC”) or were governed by state laws specifying certain criteria for making coverage or medical necessity determinations. Plaintiffs alleged that UBH’s Level of Care Guidelines and Coverage Determination Guidelines for making these determinations were more restrictive than GASC and were also more restrictive than state-mandated criteria. The district court certified three classes, conducted a bench trial, and entered judgment in Plaintiffs’ favor. The district court issued declaratory and injunctive relief, directed the implementation of court-determined claims processing guidelines, ordered “reprocessing” of all class members’ claims in accordance with the new guidelines, and appointed a special master to oversee compliance for ten years.   The Ninth Circuit affirmed in part and reversed in part. The panel held that Plaintiffs had Article III standing to bring their breach of fiduciary duty and improper denial of benefits claims. And the district court did not err in certifying three classes to pursue the fiduciary duty claim. However, because Plaintiffs expressly declined to make any showing, or seek a determination of, their entitlement to benefits, permitting Plaintiffs to proceed with their denial of benefits claim under the guise of a “reprocessing” remedy on a class-wide basis violated the Rules Enabling Act. View "DAVID WIT, ET AL V. UNITED BEHAVIORAL HEALTH" on Justia Law

Department of Labor regulations required the administrator of an employee benefit plan to give a claimant, “upon request,” copies of “all documents, records, and other information” that the administrator considered in making an adverse benefit determination. In 2018, the regulations were amended to eliminate “upon request” and require an administrator to provide such information “sufficiently in advance” of an adverse determination “to give the claimant a reasonable opportunity to respond.”Zall, a dentist for 20 years, sought long-term disability benefits in 2013 after pain and numbness forced him to stop working. His insurer, Standard denied the claim. In 2014, after considering additional medical information and consulting an orthopedic surgeon, Standard approved Zall’s claim, including retroactive payments. Less than a year later, Standard began reviewing his case to see if his condition was subject to a 24-month benefit limit applicable to any disability “caused or contributed to by … carpal tunnel or repetitive motion syndrome” or “diseases or disorders of the cervical, thoracic, or lumbosacral back and its surrounding soft tissue.” Standard ultimately terminated Zall’s benefits.Zall filed suit under the Employee Retirement Income Security Act, 29 U.S.C. 1001, arguing that the decision was arbitrary and capricious and that Standard violated ERISA’s procedural requirements by failing to afford him “a full and fair review.” The district court granted Standard summary judgment. The Seventh Circuit reversed and remanded. The plain language shows that the amended regulation applies; Standard failed to comply. View "Zall v. Standard Insurance Co." on Justia Law

The employers agreed that for the duration of two collective bargaining agreements (CBAs), they would make pension contributions on behalf of covered employees to the Pension Fund. Both CBAs contained “evergreen clauses” that extended them a year at a time until either party provided timely written notice expressing an “intention to terminate.” Both were to expire in January 2019. After the window for timely notice of intention to terminate on that date, the employers and the union signed new CBAs requiring pension contributions to a different fund beginning in February 2019. The employers notified the Fund that they were ceasing contributions, relying on letters the union sent in November 2018.The Seventh Circuit reversed the dismissal of the Fund’s lawsuit. Those letters did not express the union’s intent to terminate the existing CBAs, so as to satisfy the evergreen clause's termination procedure. The letters did not mention termination. They noted the date that the CBAs would expire and expressed a desire to meet to negotiate new agreements; neither of these points communicated an intent to terminate the existing agreements. In the context of an evergreen clause, expiration and termination are distinct concepts. A desire to negotiate a new contract is quite consistent with a desire to leave the existing agreement in place until a new deal is reached. The old agreements renewed under the evergreen clauses; the employers remained obligated to contribute to the Fund for one more year. View "Central States Southeast & Southwest Areas Pension Fund v. Zenith Logistics, Inc." on Justia Law

Gragg worked as a driver for 31 years. For the first 26 years, he was an employee of Overnite; after UPS acquired Overnite, he was an employee of UPS. In 2008, UPS reclassified his position from nonunion to union, so that two different pension plans funded his pension. In 2010, each plan sent him information indicating that, after Gragg turned 65, each plan would reduce his monthly payment by $1754, which was the anticipated amount of his Social Security benefit. Gragg turned 65 in 2018. The following month, each plan reduced the amount of Gragg’s monthly benefit by the entire amount of his Social Security benefit—for a combined monthly reduction of $3508. Gragg’s overall monthly income declined by $1754, rather than remaining stable as promised by the letters. Gragg filed suit under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(1)(B).The district court held Gragg’s suit was barred by a six-year limitations period, having accrued when he received the letters. The Sixth Circuit reversed. The letters did not cause the injury upon which Gragg sued; the underpayments did. Before that injury, his claim had not accrued. An ERISA claim based on the letters alone would have rested upon “contingent future events that may not occur as anticipated, or indeed may not occur at all.” View "Gragg v. UPS Pension Plan" on Justia Law