Justia ERISA Opinion Summaries

Central States, an employee benefit plan governed by the Employee Retirement Income Security Act, provides health insurance for Teamsters and their families. Guarantee Trust provides sports injury insurance for student athletes. Each of 13 high school and college athletes, all children of Teamsters, holds general health insurance from Central and sports injury insurance from Guarantee. Each suffered an injury while playing sports (most often football) between 2006 and 2009, and sought coverage from both companies. Each time Guarantee refused to pay the athlete’s medical expenses, and each time Central paid the bill under protest. The district court entered a declaratory judgment under ERISA, 29 U.S.C. 1132(a)(3)(B), that, when coverage of student athletes overlap, Guarantee must pay, and ordered Guarantee to reimburse Central for the payouts to the 13 students. The Sixth Circuit, affirmed in part characterizing the case as a “you first” paradox, or ‘gastonette.” An ERISA plan may coordinate benefits with another policy, but may not redefine the coverage of another policy. Absent the Central plan, the Guarantee policy would cover the sports injuries at issue without question. An ERISA plan must keep doing what it would do in another plan’s absence. That amounts to coordinating benefits, not redefining coverage. View "Cent St, SE & SW Areas Health & Welfare Fund v. First Agency, Inc." on Justia Law

Plaintiff filed suit against her former employer, Andalex, alleging claims of discrimination, retaliation, and hostile work environment under federal and state law, as well as claims that Andalex failed to notify her of her right to continuing health care coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), 29 U.S.C. 1166 et seq. The district court granted summary judgment in favor of Andalex and dismissed her claims. The court affirmed the district court's judgment except with respect to plaintiff's retaliation claims. Based on the discrepancies between the EEOC statement and subsequent testimony, a reasonable juror could infer that the explanation given by Andalex was pretextual, and that, coupled with the temporal proximity between the complaint and the termination, the complaint at issue was a but-for cause of defendant's termination. Accordingly, there was sufficient evidence to require denial of the summary judgment motion on the retaliation claims. View "Kwan v. The Andalex Group LLC" on Justia Law

Plaintiffs filed suit claiming denial of medical insurance, Medicare premiums, and deductible reimbursements. The district court held that the pension plan benefit plan was a "governmental plan" exempt from the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., and granted defendants' motion to dismiss for lack of subject matter jurisdiction. The court vacated and remanded, concluding that the district court employed the wrong procedural mechanism for analyzing this case. Because a federal district court has jurisdiction to decide whether or not a plan is an ERISA plan as claimed by plaintiffs, the court concluded that, under Supreme Court precedent and ACS Recovery Services, Inc. v. Griffin, the proper procedural vehicle to raise the question of whether a purported ERISA plan is a "governmental plan" is either Rule 12(b)(6) or, if factual information outside the pleadings is needed, Rule 56. View "Smith, et al. v. Regional Transit Auth., et al." on Justia Law

Plaintiff, a large Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., provider, sought a declaration that defendants, three independent, non-ERISA insurance providers, were bound by the terms of the ERISA plan and primarily liable for injuries sustained by individuals covered by the parties. The district court granted defendants' motion to dismiss. The court concluded that the Central States have failed to state a claim for equitable relief as required by Section 502(a)(3) of ERISA; there was no gap in ERISA's enforcement scheme requiring a federal common law claim for unjust enrichment; and Count I does not adequately state a claim for equitable relief under ERISA 502. Accordingly, the court affirmed the judgment of the district court. View "Central States, SE and SW Areas Health and Welfare Fund v. Health Special Risk, Inc., et al" on Justia Law

Plaintiffs, a group of retired U.S. Airways pilots, filed a class action seeking interest for the period of delay in the payment of their retirement benefits. The district court refused to certify the class. The court reversed and remanded, holding that the class members were not required to exhaust internal remedies before bringing their claims in court because they sought enforcement of the Employee Retirement Income Security Act's (ERISA), 29 U.S.C. 1001 et seq., substantive guarantees rather than contractual rights. View "Stephens, et al. v. US Airways Group, Inc., et al." on Justia Law

In 2000, Rochow sold his interest in Universico to Gallagher and became President of Gallagher. As an employee of Gallagher, Rochow was covered under a LINA disability policy. In 2001, Rochow began to experience short term memory loss, chills, sweating, and stress at work. Gallagher demoted Rochow to Sales Executive-Account Manager. Because of his inability to perform his job, Gallagher forced Rochow to resign in January, 2002. In February 2002, Rochow experienced amnesia, was hospitalized, and was diagnosed with HSV-Encephalitis, a rare, severely debilitating brain infection. LINA repeatedly denied Rochow benefits stating that Rochow’s employment ended before his disability began. In 2004, Rochow sued Cigna, LINA’s parent company, alleging breach of fiduciary duty under ERISA, 29 U.S.C.1104(a). In 2007 the Sixth Circuit affirmed a decision that denial of Rochow’s claims was arbitrary, not the result of a deliberate, principled reasoning process, and did not appear to have been made solely in the interest of the participants and beneficiaries or the exclusive purpose of providing benefits to participants and beneficiaries as required by ERISA. Rochow died in 2008. In 2009, the district court ordered an equitable accounting of profits and disgorgement of $3,797,867.92 under an equitable theory of unjust enrichment. The Sixth Circuit affirmed.View "Rochowl v. Life Ins. Co. of N. America" on Justia Law

Plaintiff appealed the district court's denial of her motion for judgment on the record, affirming Liberty's termination of long-term disability benefits and dismissal of the complaint with prejudice. The policy provided that an employee was not disabled if the employee was capable of performing any occupation for which he or she was reasonably fitted. The court concluded that Liberty did not abuse its discretion in determining that plaintiff was reasonably fitted to perform the occupation of ambulance/emergency service dispatcher. Therefore, the record reflected that Liberty's decision to terminate benefits was supported by substantial evidence and thus did not constitute an abuse of discretion. Accordingly, the court affirmed the judgment of the district court.View "Gerhardt v. Liberty Life Assurance Co., et al." on Justia Law

In 2000, physicians and physician associations imitated a group of class actions against various providers of health plans, which were consolidated into a multidistrict litigation. This appeal involves this complex, twelve-year-old multidistrict litigation, a related multidistrict litigation pending in another federal district, and whether the district court reasonably interpreted the Settlement Agreement in the first action. The court affirmed the Injunction as to plaintiffs' Racketeer Influenced and Corrupt Organizations Act (RICO), 18 U.S.C. 1961, and antitrust claims and as to the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001 et seq., claims based on the denial or underpayment of benefits following the Settlement Agreement's Effective Date. On remand, the district court will need to determine which of plaintiffs' ERISA claims fall on the permissible side of the line, and reconsider the assessment of sanctions. View "Medical Assoc. of GA, et al. v. Wellpoint, Inc." on Justia Law

Plaintiff received coverage under Johnson & Johnson’s Long-Term Disability Plan while working for a subsidiary of Johnson & Johnson. Later, Johnson & Johnson and Medical Card System, Inc. (together, Appellees) terminated Plaintiff’s long-term disability benefits. The district court upheld the denial, holding that the plan administrator had ample basis for finding Plaintiff did not cooperate fully during the Functional Capacity Examination (FCE) and was thus ineligible for continuing benefits. Plaintiff again appealed, arguing, among other things, that the plan administrator abused its discretion in crediting an examination by a physical therapist over the opinion of his treating physician. The First Circuit Court of Appeals affirmed, holding (1) the plan administrator’s finding that Plaintiff was uncooperative during his final FCE was supported by substantial evidence, and therefore, the administrator’s decision to terminate Plaintiff’s long-term disability benefits was neither arbitrary nor capricious; and (2) the administrator did not abuse its discretion in determining whether there existed grounds for termination of Plaintiff’s benefits. View "Ortega-Candelaria v. Johnson & Johnson" on Justia Law

From 1978 to 2000, Cerentano worked as a coal miner. He was injured in 15 mining incidents and received six separate awards of permanent partial disability, but was able to return to work after each injury. In 2000 Cerentano was wrongfully discharged after a false positive drug test. Months later, he was diagnosed with depression due to his firing and treated for dysthymia and anxiety. Eventually, Cerentano found work as a real estate agent and a vehicle transporter. In 2005, Cerentano’s car was hit, causing more injuries. Cerentano was awarded Social Security disability benefits. He was denied disability pension benefits under the United Mine Workers Pension Trust Plan, based on the trustees’ conclusion that there was no causal link between his mine injuries and the award of Social Security benefits. Cerentano sued under the Employee Retirement Income Security Act, 29 U.S.C. 1332(a)(1)(b). The district court granted summary judgment to the plan. The Seventh Circuit reversed and remanded. The trustees should have examined all of the injuries, severe and non‐severe, that the ALJ relied on in finding Cerentano disabled and should have determined which of those injuries were caused by mine accidents and whether, the mine‐related injuries, in combination, comprised “a causal link.”View "Cerentano v. UMWA Health & Retirement Funds" on Justia Law