Justia Insurance Law Opinion Summaries

Articles Posted in ERISA
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Nancy Stark, as the legal guardian and mother of Jill Finley, an incapacitated person, filed a lawsuit against Reliance Standard Life Insurance Company. Finley, who suffered a hypoxic brain injury in 2007, was initially approved for long-term disability benefits by Reliance. However, in 2022, Reliance terminated her benefits, claiming recent testing did not support her total disability. Stark appealed, and Reliance reinstated the benefits in 2023. Stark then sued, seeking a surcharge for financial harm caused by the wrongful termination, claiming breach of fiduciary duty for not providing internal records, and contesting the deduction of social security payments from Finley's disability payments.The United States District Court for the Western District of Oklahoma granted Reliance's motion to dismiss under Rule 12(b)(6) for failure to state a claim. The court found that Stark did not plausibly allege a claim for equitable relief under ERISA, nor did she demonstrate that Reliance's actions violated the terms of the insurance policy or breached fiduciary duties.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court affirmed the district court's dismissal, holding that Stark was not entitled to attorney’s fees incurred during the administrative appeal under ERISA’s § 1132(a)(3) or § 1132(g). The court also found that Stark's claims regarding the SSD offset were time-barred and waived due to failure to exhaust administrative remedies. Additionally, the court concluded that Stark did not allege any concrete harm resulting from Reliance's alleged failure to provide requested records during the administrative appeal. Consequently, the Tenth Circuit affirmed the district court's decision to dismiss all of Stark's claims. View "Stark v. Reliance Standard Life Insurance Company" on Justia Law

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Two hospitals in Tennessee, Saint Francis Hospital and Saint Francis Hospital-Bartlett, sued Cigna Health and Life Insurance Company, claiming that Cigna routinely underpaid them for emergency services provided to Cigna members. The hospitals, which are out-of-network providers for Cigna, argued that Cigna had a quasi-contractual obligation to pay the reasonable value of their services based on federal and state laws requiring hospitals to treat emergency patients and insurers to cover emergency care.The United States District Court for the Western District of Tennessee dismissed the hospitals' claims. The court found that the hospitals' complaint did not meet the pleading standards of Rule 8, that Tennessee common law did not support their claims, and that the Employee Retirement Income Security Act (ERISA) preempted their claims.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court's dismissal. The Sixth Circuit held that neither federal law (specifically the Affordable Care Act) nor Tennessee law imposed a duty on Cigna to pay the full value of out-of-network emergency services. The court noted that the ACA's requirement for insurers to provide "coverage" for emergency services did not mean that insurers had to pay the full cost. The court also found that Tennessee common law did not support the hospitals' claims for quantum meruit and unjust enrichment, as there was no contractual or statutory duty for Cigna to pay the full value of the services.The Sixth Circuit concluded that the hospitals' claims failed because they could not establish that Cigna had a legal obligation to pay more than what was stipulated in its contracts with its members. The court did not address the ERISA preemption issue, as the dismissal was affirmed on other grounds. View "AMISUB (SFH), Inc. v. Cigna Health & Life Ins. Co." on Justia Law

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Pamela Edwards, owner of Allure Salon in Starkville, Mississippi, was diagnosed with cancer in 2019 and passed away in 2022. After her death, her husband, Jimmy Edwards, sought payment from her life insurance policy with Guardian Life Insurance. Guardian denied the claim, stating the policy had been canceled because the number of insured employees at Allure dropped to one, triggering their right to cancel the policy. Jimmy Edwards was unaware of the policy until informed by the insurance agent, Debbie Jaudon, who also did not receive a cancellation notice from Guardian.Jimmy Edwards sued Guardian in the Northern District of Mississippi, bringing claims under Mississippi common law and arguing that ERISA entitled him to recover benefits. Guardian moved for partial summary judgment, asserting that ERISA governed the plan and preempted the common-law claims. The district court granted Guardian’s motion, and Jimmy Edwards appealed.The United States Court of Appeals for the Fifth Circuit reviewed the case. The court determined that ERISA applied to the Allure policy, as the salon technicians were considered employees under federal common law. The court found that Guardian had waived its right to cancel the policy by continuing to accept premium payments for 26 months after the right to cancel vested. The court held that Guardian could not avoid its obligation to pay the claim after accepting premiums for such an extended period. Consequently, the Fifth Circuit reversed the district court's judgment and rendered judgment in favor of James Edwards. View "Edwards v. Guardian Life Insurance" on Justia Law

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J.H. participated in an employee welfare-benefit plan insured by Anthem Blue Cross Life and Health Insurance Company, with her son, A.H., as a beneficiary. After seeking benefits for A.H.'s yearlong stay at a mental-health treatment center, Anthem denied coverage, and Plaintiffs' appeal to Anthem was unsuccessful. Over a year after their final appeal through Anthem was decided, Plaintiffs filed a lawsuit to recover benefits under § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (ERISA).The United States District Court for the District of Utah dismissed the action, concluding it was time-barred under a provision of the Plan that required civil actions under ERISA § 502(a) to be brought within one year of the grievance or appeal decision. Plaintiffs argued that another sentence in the Plan set a three-year limitations period, creating an ambiguity that should be interpreted in their favor.The United States Court of Appeals for the Tenth Circuit reviewed the case and held that the two provisions were not inconsistent and both applied. The court explained that the one-year limitations period for § 502(a) actions and the three-year limitations period for other actions were distinct and could both be applicable. The court affirmed the district court's dismissal, concluding that Plaintiffs' action was time-barred as it was filed beyond the one-year limitations period specified in the Plan. View "J.H. v. Anthem Blue Cross Life and Health Insurance" on Justia Law

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BlueCross BlueShield of Tennessee (BlueCross) is an insurer and fiduciary for an ERISA-governed group health insurance plan. A plan member in New Hampshire sought coverage for fertility treatments, which BlueCross denied as the plan did not cover such treatments. The Commissioner of the New Hampshire Insurance Department initiated an enforcement action against BlueCross, alleging that the denial violated New Hampshire law, which mandates coverage for fertility treatments. BlueCross sought to enjoin the state regulatory action, arguing it conflicted with its fiduciary duties under ERISA.The United States District Court for the Eastern District of Tennessee denied BlueCross's request for relief and granted summary judgment to the Commissioner. The court found that the Commissioner’s enforcement action was against BlueCross in its capacity as an insurer, not as a fiduciary, and thus was permissible under ERISA’s saving clause, which allows state insurance regulations to apply to insurers.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court’s decision. The Sixth Circuit held that the Commissioner’s action was indeed against BlueCross as an insurer, aiming to enforce New Hampshire’s insurance laws. The court noted that ERISA’s saving clause permits such state actions and that BlueCross could not use its fiduciary duties under ERISA to evade state insurance regulations. The court also referenced the Supreme Court’s decision in UNUM Life Insurance Co. of America v. Ward, which established that state insurance regulations are not preempted by ERISA when applied to insurers. Thus, the Sixth Circuit concluded that ERISA did not shield BlueCross from the New Hampshire regulatory action. View "BlueCross BlueShield of Tennessee v. Nicolopoulos" on Justia Law

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Plaintiffs M.S. and L.S. sought insurance coverage for mental health treatments for their child, C.S., under a health benefits plan provided by M.S.'s employer, Microsoft Corporation. The plan, administered by Premera Blue Cross, is subject to ERISA and the Parity Act. Premera denied the claim, stating the treatment was not medically necessary. Plaintiffs pursued internal and external appeals, which upheld the denial. Plaintiffs then sued in federal district court, alleging improper denial of benefits under ERISA, failure to produce documents in violation of ERISA’s disclosure requirements, and a Parity Act violation for applying disparate treatment limitations to mental health claims.The United States District Court for the District of Utah granted summary judgment to Defendants on the denial-of-benefits claim but ruled in favor of Plaintiffs on the Parity Act and ERISA disclosure claims. The court found that Defendants violated the Parity Act by using additional criteria for mental health claims and failed to disclose certain documents required under ERISA. The court awarded statutory penalties and attorneys’ fees to Plaintiffs.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court vacated the district court’s grant of summary judgment on the Parity Act claim, finding that Plaintiffs lacked standing to bring the claim. The court reversed the district court’s ruling that Defendants violated ERISA by not disclosing the Skilled Nursing InterQual Criteria but affirmed the ruling regarding the failure to disclose the Administrative Services Agreement (ASA). The court upheld the statutory penalty for the ASA disclosure violation and affirmed the award of attorneys’ fees and costs to Plaintiffs. View "M.S. v. Premera Blue Cross" on Justia Law

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Plaintiffs Marla Knudsen and William Dutra, representing a class of similarly situated individuals, filed a class action lawsuit under the Employee Retirement Income Security Act (ERISA) against MetLife Group, Inc. They alleged that MetLife, as the administrator and fiduciary of the MetLife Options & Choices Plan, misappropriated $65 million in drug rebates from 2016 to 2021. Plaintiffs claimed this misappropriation led to higher out-of-pocket costs for Plan participants, including increased insurance premiums.The United States District Court for the District of New Jersey dismissed the case for lack of standing. The court concluded that the plaintiffs did not demonstrate a concrete and individualized injury. It reasoned that the plaintiffs had no legal right to the general pool of Plan assets and had not shown that they did not receive their promised benefits. The court found the plaintiffs' claims that they paid excessive out-of-pocket costs to be speculative and lacking factual support.The United States Court of Appeals for the Third Circuit affirmed the District Court's dismissal. The Third Circuit held that the plaintiffs failed to establish an injury-in-fact, as their allegations of increased out-of-pocket costs were speculative and not supported by concrete facts. The court noted that the plaintiffs did not provide specific allegations showing how the misappropriated drug rebates directly caused their increased costs. The court emphasized that financial harm must be actual or imminent, not conjectural or hypothetical, to satisfy Article III standing requirements. Consequently, the plaintiffs lacked standing to pursue their ERISA claims. View "Knudsen v. MetLife Group Inc" on Justia Law

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Mychal Byrd was injured in an automobile accident caused by an unknown motorist and subsequently died from his injuries. Byrd's medical expenses, totaling $474,218.24, were covered by the Gilster-Mary Lee Corporation Group Health Benefit Plan, a self-funded plan subject to ERISA. Byrd had an automobile insurance policy with Nationwide Insurance Company, which provided $50,000 in uninsured-motorist coverage. After Byrd's death, his family sued Nationwide in state court to collect the insurance proceeds. The Plan intervened, removed the case to federal court, and claimed an equitable right to the insurance proceeds.The United States District Court for the Eastern District of Missouri granted summary judgment in favor of the Plan, determining that the Plan was entitled to the insurance proceeds under the plan document. The plaintiffs, initially proceeding pro se, did not respond to the motion for summary judgment. After obtaining counsel, they moved for reconsideration, which the district court denied. The plaintiffs then appealed the decision.The United States Court of Appeals for the Eighth Circuit reviewed the case and concluded that the district court lacked subject-matter jurisdiction. The appellate court determined that the plaintiffs' claim did not fall within the scope of ERISA's civil enforcement provisions because the plaintiffs were neither plan participants nor beneficiaries. Consequently, the claim was not completely preempted by ERISA, and the federal court did not have jurisdiction. The Eighth Circuit vacated the district court's judgment and remanded the case with instructions to return it to Missouri state court. View "Kellum v. Gilster-Mary Lee Corporation Group Health Benefit" on Justia Law

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Paul Carnes, an employee of Consolidated Grain and Barge Co., was diagnosed with degenerative disc disease in 2019 and received medical treatment for it. HMO Louisiana, Inc., the administrator of Consolidated Grain’s employer-sponsored health plan governed by ERISA, paid for some of Carnes’s treatments but not all. Carnes filed a workers’ compensation claim against his employer, which was settled without the employer accepting responsibility for his medical claims. With an outstanding medical balance of around $190,000, Carnes sued HMO Louisiana, alleging it violated Illinois state insurance law by not paying his medical bills and sought penalties for its alleged "vexatious and unreasonable" conduct.The United States District Court for the Central District of Illinois dismissed Carnes’s complaint on the grounds that his state law insurance claim was preempted by ERISA. The court allowed Carnes to amend his complaint to plead an ERISA claim, but instead, Carnes moved to reconsider the dismissal. The district court denied his motion and ordered the case closed. Carnes then appealed the final order.The United States Court of Appeals for the Seventh Circuit reviewed the case de novo. The court affirmed the district court’s decision, agreeing that Carnes’s state law claim was preempted by ERISA. The court noted that ERISA’s broad preemption clause supersedes any state laws relating to employee benefit plans, and Carnes’s claim fell within this scope. The court also found that ERISA’s saving clause did not apply because the health plan in question was self-funded, making it exempt from state regulation. The court concluded that Carnes’s attempt to frame his suit as a "coordination of benefits dispute" was an impermissible effort to avoid ERISA preemption. Consequently, the court affirmed the dismissal of Carnes’s case. View "Carnes v. HMO Louisiana, Inc." on Justia Law

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Joel M. Guy, Jr. murdered his parents in 2016 with the intent to collect the proceeds from his mother’s insurance plans. His mother had life insurance and accidental death and dismemberment insurance through her employer, naming Guy and his father as beneficiaries. Guy was convicted of first-degree premeditated murder, felony murder, and abuse of a corpse by a Tennessee jury.The United States District Court for the Eastern District of Tennessee determined that Guy would be entitled to the insurance proceeds if not disqualified. However, the court ruled that Guy was disqualified under Tennessee’s slayer statute or federal common law, which prevents a murderer from benefiting from their crime. The court granted summary judgment in favor of Guy’s family members, who argued that Guy was not entitled to the benefits. Guy appealed, arguing that ERISA preempts Tennessee’s slayer statute and that no federal common-law slayer rule applies.The United States Court of Appeals for the Sixth Circuit reviewed the case de novo. The court held that ERISA does not explicitly address the issue of a beneficiary who murders the insured, and thus, either Tennessee law or federal common law must apply. The court found that both Tennessee’s slayer statute and federal common law would disqualify Guy from receiving the insurance proceeds. The court affirmed the district court’s decision, concluding that Guy’s actions disqualified him from benefiting from his mother’s insurance plans under both state and federal law. View "Standard Insurance Co. v. Guy" on Justia Law