Justia Insurance Law Opinion Summaries

In this case, participants in the Thunderbird Mining Company Pension Plan sought "shutdown" pension benefits. The PBGC, the government agency that administered pension termination insurance under Title IV of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001-1461, denied the participants' request. These early retirement benefits were triggered by a permanent shutdown of a plant and were payable to plan participants who met certain age and years-of-service requirements. The court held that the agency's determination was not arbitrary or capricious where the record provided sufficient support for the agency's judgment that a permanent shutdown had not occurred before Eveleth's pension plan was terminated on July 24th, 2003. Accordingly, the court affirmed the district court's grant of summary judgment in favor of the agency. View "United Steel, et al. v. Pension Benefit Guaranty Corp." on Justia Law

This appeal arose from a dispute between Unum and the late Kevin Sullivan over long-term disability benefit payments. Sullivan sued Unum, arguing that the termination of his benefits violated the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq., and Unum counterclaimed for overpayment of benefits. The court concluded that it was not an abuse of discretion for the administrator to determine that the large payments that Sullivan received in 2004 were payments for the sale of a business for the purpose of calculating his benefits. Unum asserted that the payments were salary, not income. The court reversed the district court's grant of summary judgment and award of attorney's fees, remanding for consideration of Unum's counterclaims. View "Sullivan v. Unum Life Ins. Co., et al" on Justia Law

Plaintiff appealed the district court's grant of summary judgment to the Plan on his claim under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. Plaintiff asserted that the Plan did not comply with procedures set out by ERISA by changing its basis for denial on administrative appeal and by not identifying the independent physician reviewer who recommended denial on administrative appeal. Because plaintiff did not specify the failure to identify the physician in his amended complaint, the court did not address this issue. The court agreed with plaintiff, however, that the Plan did not substantially comply with ERISA procedures by changing its basis for denying coverage on administrative appeal. The court concluded that remand to the Plan for a full and fair review was appropriate. View "Rossi v. Precision Drilling Oilfield Svcs. Corp. Emp. Benefits Plan" on Justia Law

A third-party administrator of medical benefits plans, IMA, denied claims made on behalf of two patients who received treatment from the same medical provider, LifeCare. The court held that IMA incorrectly interpreted the plans because it categorized LifeCare as a skilled nursing facility (SNF) without finding that LifeCare "fully meets all of" the plans' seven SNF factors. IMA abused its discretion because categorizing LifeCare as an SNF without considering the seven-factors SNF test contradicted the plain language of the plans. The court found that the district court correctly held that LifeCare could maintain an action against IMA pursuant to 29 U.S.C. 1132(a)(1)(B) and that IMA was liable for exercising actual control over the claims process. The court further held that the district court did not abuse its discretion in awarding attorneys' fees. View "Lifecare Mgmt. Svcs., LLC v. Ins. Mgmt. Admins. Inc, et al" on Justia Law

Plaintiff, a former software developer for Lockheed Martin Corporation, brought this action for judicial review after Connecticut General terminated his disability benefits in 2007. The court held that the district court properly applied an abuse of discretion standard; on the record, it was not an abuse of discretion to terminate plaintiff's benefits; and the district court did not err in denying plaintiff an opportunity to depose the expert at issue. Accordingly, the court affirmed the judgment. View "Siegel v. Connecticut General Life Ins., et al" on Justia Law

In 1992 Navistar attempted to reduce its costs for retired employee health and life insurance benefits. Navistar’s retirement benefit plan is a registered employee health benefit plan under the Employee Retirement Income Security Act, 29 U.S.C. § 1001 and Navistar is both plan administrator and fiduciary. In 1993, the district court entered judgment in a class action challenging the change, adopting an agreement between the parties and retaining jurisdiction. The Agreement established the Retiree Health Benefit and Life Insurance Plan. The Plan established the Health Benefit Program Summary Plan Description, which contains a description of the health benefits and is furnished to all beneficiaries. The Agreement divides health benefits into two plans: Plan 2 for those eligible for Medicare and Plan 1 for those who are not eligible. A prescription drug benefit was provided under the Agreement, identical for both Plan 1 and Plan 2. When Navistar moved to substitute Medicare Part D into the Plan, class members claimed violation of the Agreement. The district court ordered Navistar to reinstate, retroactively, the prescription drug benefit that was in effect before Navistar made the unilateral substitution. The Sixth Circuit affirmed,View "Shy v. Navistar Int'l Corp." on Justia Law

Raybourne was a quality engineer for 23 years. The employer provided a long-term disability plan that paid benefits for up to 24 months if disability prevented him from performing the duties of his regular job. After 24 months, the plan paid benefits only if he was unable to perform all material duties of any occupation for which he was reasonably qualified. Raybourne suffered degenerative joint disease in his foot, with severe pain. In 2003, he stopped working and underwent the first of the four surgeries. From December 2003 through February 2006, Cigna paid benefits, then determined that he was not disabled under the more stringent standard. Raybourne exhausted administrative remedies, then sued under 29 U.S.C. 1132(a)(1)(B). The district court ruled in favor of Cigna. On remand the court rejected Cigna’s “unconvincing” explanation for how the company determined that Raybourne was not disabled. The court found that Cigna relied on the report of a non-treating physician and on the Social Security Administration’s initial rejections of Raybourne’s claim, failing to consider the SSA’s final determination of disability. The Seventh Circuit affirmed, finding that denial of benefits was based on a conflict of interest rather than on the facts and the terms of the policy. View "Raybourne v. CIGNA Life Ins. Co. of NY" on Justia Law

Decedent, father of plaintiffs, died without naming a beneficiary of his Unum life insurance. Plaintiffs sued Unum, asserting a breach of the policy and an Employee Retirement Income Security Act, 29 U.S.C. 1002 et seq., violation. The district court concluded that they lacked standing and dismissed the suit. The court concluded that the estate's decision not to appeal precluded the children from having a reasonable or colorable claim to benefits. Because plaintiffs could not become entitled to benefits, the court held that the district court properly dismissed the case. View "A.J., et al v. UNUM, et al" on Justia Law

In a 2009 opinion, the Sixth Circuit held that, in a 1998 collective bargaining agreement, CNH agreed to provide health-care benefits to retirees and their spouses for life, but rejected the suggestion that the scope of this commitment in the context of healthcare benefits, as opposed to pension benefits, meant that CNH could make no changes to the healthcare benefits provided to retirees. The court remanded for a determination of reasonableness with respect to CNH’s proposed changes to its retiree healthcare benefits, under which retirees, previously able to choose any doctor without suffering a financial penalty, would be put into a managed-care plan. The court listed three considerations: Does the modified plan provide benefits “reasonably commensurate” with the old plan? Are the proposed changes “reasonable in light of changes in health care”? And are the benefits “roughly consistent with the kinds of benefits provided to current employees”? On remand, the district court granted CNH summary judgment without reaching the reasonableness question or creating a factual record from which the determination could be made on appeal. The Sixth Circuit again remanded.View "Reese v. CNH America LLC" on Justia Law

Defendant Goding was a beneficiary of an Employee Retirement Insurance Security Act (ERISA), 29 U.S.C. 1001 et seq., Plan administered by Drury. Goding sustained injuries in a slip and fall accident and received benefits from the Drury-administered Plan, as well as compensation through the settlement of a civil suit related to those injuries. Pursuant to a subrogation provision in the ERISA Plan, Drury attempted to secure reimbursement from Goding for the benefits it paid but was unable to do so after Goding declared bankruptcy. Drury then attempted to obtain that reimbursement from the firm that represented Goding. The court affirmed the district court's finding that Drury could not obtain such reimbursement because the firm had not agreed to the Plan's subrogation provision and consequently was not contractually bound by it; Drury could not maintain a suit against the firm in equity and could not bring a state cause of action for conversion against the firm; and the firm should be awarded attorneys' fees for successful defense of a subsequent motion. View "Treasurer, Trustees of Drury Ind. v. Goding, et al." on Justia Law