Justia Insurance Law Opinion Summaries

A class of retirees who had worked under a collective bargaining agreement and their survivors and dependents obtained monetary damages and declaratory and injunctive relief requiring that defendants provide vested lifetime healthcare benefits to the class members depending on the relevant date of retirement (Employee Retirement Income Security Act of 1974, 29 U.S.C. 1132(a)(1)(B); Labor-Management Relations Act, 29 U.S.C. 185). The Sixth Circuit affirmed, holding that defendant Newell Window is bound as a successor liable under earlier collective bargaining agreements to which it was not a party; that members of the plaintiff class had vested rights to company-paid health insurance and/or Medicare Part B premium reimbursements; and that the claims were not barred by the applicable six-year statute of limitations.

Participants in an employer-sponsored 401(k) plan brought suit under the Employment Retirement Income Security Act of 1974, 29 U.S.C. 1001, and the Investment Company Act of 1940, 15 U.S.C. 80a-1, claiming excessive fees on annuity insurance contracts offered to plan participants. The district court dismissed the ICA claims because only those maintaining an ownership interest in the funds could sue under the derivative suit provision and the participants are no longer investors in the funds in question. As to the ERISA claims, the court dismissed because participants failed to make a pre-suit demand upon the plan trustees to take appropriate action and failed to join the trustees as parties. The Third Circuit affirmed with regards to the ICA claims, but vacated on the ERISA counts, holding that the statute does not require pre-suit demand or joinder of trustees.

In 2005, the Secretary of Labor filed suit for breach of fiduciary duty, alleging that defendants had established a health benefit plan that was a multi-employer welfare arrangement governed by the Employee Retirement Income Security Act. Defendants had retained, as compensation, a substantial portion of payments made by businesses to enroll their employees. The complaint alleged improper diversion of funds and that defendants were required by ERISA to use the assets only for the defraying reasonable plan expenses for the benefit of plan participants. The district court ruled in favor of defendants. The Third Circuit vacated, characterizing the scheme appearing to be "an aggressively marketed, but inadequately funded health benefit plan masquerading as an ERISA-exempt plan in order to evade the solvency controls imposed by state insurance regulation."

Plaintiffs brought a putative class action under the Employee Retirement Income Security Act, 29 U.S.C. 1001, to recover benefits under long-term disability benefit plans maintained by their former employers. The plans provide for reduction of benefits if the disabled employee also receives benefits under the Social Security Act, as both plaintiffs do. They dispute calculation of the reduction, claiming that the plans do not authorize inclusion in the offset of benefits paid to dependent children. Both plans require offsets for "loss of time disability" benefits. The district court dismissed. The Seventh Circuit affirmed, holding that children's Social Security disability benefits paid based on a parent's disability are "loss of time disability" benefits under the language of the plans.

Plaintiff commenced this action under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., claiming that the administrator of the Principal Life policies had misconstrued the policies in calculating his predisability earnings and that, with a proper calculation, his predisability earnings were far greater. The district court, ruling on cross-motions for summary judgment, entered judgment in favor of Principal Life. The court affirmed. Even though the court recognized that the policy language, defining those expenses that could be subtracted from gross income to arrive at predisability earnings, was somewhat confusing and, to be sure, needlessly verbose, the court concluded that the administrator's interpretation was a reasonable one.

Decedent worked for the company from 1982 until 1997, when, at age 52, he was treated for degenerative disc changes, alcohol abuse, and depression. He never returned to work and died in 2008. He was enrolled in his employer's group life, administered by defendant under the Employee Retirement Income Security Act, 29 U.S.C. 1001, was a participant in a long-term disability benefits plan, and had purchased an individual life insurance policy from defendant. He applied for premium waivers under the life insurance policies and received disability benefits under Social Security Disability Insurance and under the employer's plan. Defendant granted a waiver of premiums under the individual policy, but denied a waiver under the group policy. Decedent did not learn about the denial until seven years later. In 2006 and 2008, defendant again denied the application. The estate filed suit in 2010 to recover life insurance benefits and enforce rights under the group policy. The district court granted summary judgment for defendant. The First Circuit reversed, noting defendant's many mistakes in handling the claim and that defendant did not reserve to itself discretion as to interpretation and administration of its plan. Decedent was "totally disabled" for purposes of the plan.

Appellant appealed the district court's adverse grant of summary judgment in favor of Standard Insurance in this Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., benefits case. The court held that the Plan administrator did not abuse its considerable discretion in this case where substantial evidence supported the administrator's decision.

Respondent, an insurer/managed care organization, contracted with an endoscopy center and gastroenterology center (collectively, the Clinic) to provide health care services to its insureds. After the Nevada Health District found that the Clinic engaged in a number of unsafe medical practices, Respondent terminated its contract with the Clinic. Janice Munda was insured by Respondent through her employer's health plan, which was governed by ERISA. Munda was diagnosed with hepatitis C, which the Health District determined she contracted as a result of being treated at the Clinic. Janise and her husband (collectively, Appellants) sued Respondent for negligence, negligence per se, breach of implied covenant of good faith and fair dealing, and loss of consortium. The district court granted Respondent's motion to dismiss, finding that Appellants' claims were preempted by ERISA. The Supreme Court reversed, holding that under the facts, there was no preemption because Respondent's alleged actions were independent of the administration of the ERISA plan.

Plaintiff, an RN, stopped working at the hospital and went on disability only a few months after starting work. Her symptoms were attributed to chronic pancreatitis, chronic pain syndrome or fibromyalgia; she took "impressive amounts of narcotics" to manage her pain, which caused negative side effects. After about five years, the company terminated benefits, finding that she was not totally disabled, as defined by the policy. The district court upheld the termination in a suit under the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). The First Circuit remanded for further review, reasoning that plaintiff's activities, shown on surveillance tapes, and the lack of clinical documentation were overstated.

After defendant was in a serious automobile accident, a benefit plan administered by plaintiff paid $66,866 for his medical expenses. Defendant then recovered $110,000 from third parties, with the assistance of counsel. Plaintiff, which had not sought to enforce its subrogation rights, demanded reimbursement of the entire $66,866 it had paid without allowance for legal costs, which had reduced defendant's net recovery to less than the amount it demanded. Plaintiff sued for "appropriate equitable relief" pursuant to the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(3) B). The district court ordered plaintiff to pay the entire. $66,866. The Third Circuit vacated, holding that defendant may assert equitable limitations, such as unjust enrichment, on plaintiff's equitable claim.