Justia Insurance Law Opinion Summaries

Frazier, a sorter for Publishers Printing, was covered by Publishers’ employee benefit plan, which provided disability insurance. In 2009, at age 42, she left her job due to back pain that radiated down her legs, which she thought was caused by arthritis and a bulging disc, though she could not remember any fall or injury that initiated the pain. An MRI revealed mild disc dislocation. Her family physician diagnosed her with lower back pain and radiculopathy and in 2010 opined that Frazier was unable to return to work at regular capacity. Frazier participated in limited physical therapy. Another physician prescribed lumbar epidural injections and eventually permitted her to return to work. The plan denied Frazier’s claim for long-term disability benefits after reviewing medical evidence and job descriptions from Publishers and the U.S. Department of Labor. A Functional Capacity Evaluation indicated that Frazier “is currently functionally capable of meeting the lower demands for the Medium Physical Demand level on a 8 hour per day.” Frazier sued under the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court granted judgment for the plan, reasoning that the administrator had discretion to deny Frazier’s claim, and that denial of benefits was not arbitrary. The Sixth Circuit affirmed. View "Frazier v. Life Ins. Co. of N. Am." on Justia Law

Tennessee resident Lombard acquired a 1997 Lincoln Town Car in 2004. The car was partially manufactured, and its final assembly completed, in 1996 at Ford’s Wixom, Michigan plant. In March 2007, the Lincoln, which was licensed, registered, and insured in Tennessee, allegedly caught fire in Lombard’s driveway, causing damage to the car, Lombard’s residence, and personal property. Lombard’s insurers reimbursed Lombard for his losses and, as subrogees, sued Ford, asserting products liability, breach of warranty and negligence claims, alleging that the fire was due to a defective cruise control system. The district court dismissed, finding that Tennessee law governed and that Tennessee’s statute of repose for products liability actions bars the claims. The Sixth Circuit affirmed, after examining Michigan choice of law rules. The conclusion that Michigan’s interests do not “mandate” that Michigan law be applied despite Tennessee’s interests was not erroneous. View "Std. Fire Ins. Co. v. Ford Motor Co." on Justia Law

The plant’s union and TRW negotiated collective bargaining agreements, which included provisions for healthcare benefits for retirees. The last CBA became effective in 1993 and was scheduled to expire in 1996. The plant closed in 1997. TRW and the union entered into a termination agreement that provided that any beneficiary, who is receiving or entitled to receive any payment and/or benefit under the CBA, “shall continue to receive or be entitled to receive such payment and/or benefit as though the CBA and Pension Plan had remained in effect.” In 2011, TRW terminated prescription drug coverage for Medicare-eligible retirees, replacing it with an annual contribution to a health reimbursement account. Plaintiffs claimed that this change modified their benefits in violation of TRW’s contractual obligation and filed a purported class action under the Labor Management Relations Act, 29 U.S.C. 185(a), and a claim for benefits under the Employment Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). The district court granted TRW’s motion to compel arbitration. The Sixth Circuit affirmed as to the two named Plaintiffs, declining to address the rights of hypothetical plaintiffs. View "VanPamel v. TRW Vehicle Safety Sys., Inc." on Justia Law

The Fund is a multi-employer trust fund under the Taft-Hartley Act, 29 U.S.C. 186, and the Employee Retirement Income Security Act, 29 U.S.C. 1001. Blue Cross is a Michigan non-profit corporation; its enabling statute authorizes the State Insurance Commissioner to require it to pay a cost transfer of one percent of its “earned subscription income” to the state for use to pay costs beyond what Medicare covers. In 2002 the Fund converted to a self-funded plan, and entered into an Administrative Services Contract with Blue Cross, which states that Blue Cross is not the Plan Administrator, Plan Sponsor, or fiduciary under ERISA; its obligations are limited to processing and paying claims. In 2004 the Fund sued, claiming that Blue Cross breached ERISA fiduciary duties by imposing and failing to disclose a cost transfer subsidy fee to subsidize coverage for non-group clients. The fee was regularly collected from group clients. Self-insured clients were not always required to pay it. Following a first remand, the district court granted class certification and granted the Fund summary judgment. On a second remand, the court again granted judgment on the fee imposition claim and awarded damages of $284,970.84 plus $106,960.78 in prejudgment interest. The Sixth Circuit affirmed. View "Pipefitters Local 636 Ins. Fund v. Blue Cross & Blue Shield of MI" on Justia Law

Engleson, vice president of an Akron insurance agency, suffered from medical conditions, including Crohn’s disease and depression. He resigned in 2001 and sought long-term disability benefits from the company’s group plan, managed by Unum. Unum denied his claim weeks later, reasoning that Engleson’s clinical documentation did not establish that his symptoms were so debilitating that he was precluded from working. Unum denied an appeal in October, 2001 and a second appeal with additional supporting information in November, 2001. In 2007, Engleson returned to Ohio and to the agency, but in August, 2008, he filed another claim for disability benefits. Unum granted his request, with the date of disability denoted as August 5, 2008. Unum would not provide additional appeal review of the 2001 claim. Engleson filed suit in 2009, under 29 U.S.C. 1132(a)(1)(B) and the Employee Retirement Income Security Act, alleging that he was not afforded a full and fair review of his claim and that Unum breached its fiduciary duties. The district court held that the three-year contractual limitations period barred the suit with respect to his 2001 claim. The Sixth Circuit affirmed, holding that the untimely filing was not excusable. View "Engleson v. UNUM Life Ins. Co. of Am." on Justia Law

Judge, who worked as an airline baggage handler and ramp agent for 20 years, underwent surgery to repair an aortic valve and a dilated ascending aorta. He applied for disability benefits under a group insurance policy issued by MetLife. MetLife denied benefits, finding that Judge was not totally and permanently disabled under the terms of the Plan. After exhausting internal administrative procedures, Judge sued to recover benefits under 29 U.S.C. 1132(a)(1)(B), the Employee Retirement Income Security Act (ERISA). The district court granted judgment on the administrative record in favor of MetLife. The Sixth Circuit affirmed, rejecting arguments that MetLife applied the wrong definition of “total disability,” erred in failing to obtain vocational evidence before concluding that Judge was not totally and permanently disabled, erred in conducting a file review by a nurse in lieu of having Judge undergo independent medical examination, and that there was a conflict of interest because MetLife both evaluates claims and pays benefits under the plan. View "Judge v. Metro. Life Ins. Co." on Justia Law

Plaintiffs, 91 current and former special investigators (SIs) employed by Nationwide Mutual Insurance claimed that Nationwide improperly classified SIs as administrative employees exempt from the overtime requirements of the Fair Labor Standards Act, 29 U.S.C. 207 and 213(a)(1)) and analogous provisions of New York and California law. The district court entered partial summary judgment in favor of Nationwide, then ruled in the company’s favor following trial on other issues. The Sixth Circuit affirmed. A reference to investigators, 29 C.F.R. 541.3(b)(1), read in context, pertains to law enforcement and public safety personnel and not to the Sis employed by Nationwide. Plaintiffs perform work “directly related” to Nationwide’s “general business operations.” The district court properly found that their investigations, with the purpose of resolving the indicators of fraud and the legitimacy of the suspicious claims, are unlike the narrower more formulaic background investigations into facts and records that have been found to not involve the exercise of discretion and independent judgment with respect to matters of significance. View "Foster v. Nationwide Mut. Ins. Co" on Justia Law

Pagliara, a licensed securities broker for more than 25 years, maintained a spotless record with the Financial Industry Regulatory Authority (FINRA) except for this case. Under a 2002 licensing agreement, Pagliara served both Capital Trust and NBC until 2008. During that time, Butler followed Pagliara’s recommendation to invest $100,000 in bank stocks that later lost value. Butler’s attorney threatened to sue NBC and Pagliara. NBC retained JBPR for defense. Unbeknownst to NBC and JBPR, Pagliara offered to settle the claim for $14,900, $100 below FINRA’s mandatory reporting threshold. Butler refused. Pagliara then informed NBC of his intent to defend the claim in FINRA Arbitration and objected to any settlement of the “frivolous claim.” NBC insisted that Pagliara not have any contact with Butler, based on the License Agreement signed by the parties, which stated that: “NBCS, at its sole option and without the prior approval of either [Capital Trust] or the applicable Representative, may settle or compromise any claim at any time.” JBPR finalized a $30,000 settlement without obtaining a release for Pagliara. Pagliara sued, alleging breach of fiduciary duty, violation of the Tennessee Consumer Protection Act, and intentional infliction of harm. The district court rejected the claims. The Sixth Circuit affirmed. View "Pagliara v. Johnston Barton Proctor & Rose, LLP" on Justia Law

The Fund, a multi-employer pension plan under ERISA, has a Plan, providing for administration by a Board with authority to make benefit determinations and amend the Plan, including retroactively. No amendment may result in reduced benefits for any participant whose rights have vested, except in specified circumstances. Price began receiving Plan disability benefits under the “Total and Permanent Disability Benefit” category in 1990, after work-related injuries left him unable to work. In 2001, the Fund notified Price that he no longer qualified for benefits under this category, but that he could continue receiving benefits under provisions for “Occupational Disability Benefit.” His benefits were discontinued after 2006, according to an Amendment. Price became eligible for early retirement in 2012. The Board rejected an appeal. The district court granted Price judgment in his suit under ERISA, 29 U.S.C. 1132(a)(1)(B). On remand from the Sixth Circuit, for review determination of vesting under the arbitrary and capricious standard, the judge again ruled in favor of Price. The Sixth Circuit again reversed; the court failed to look to the terms of the plan but instead found that because the Board’s decision letter did not discuss whether the benefits vested, the Board’s decision was arbitrary and capricious. View "Price v. Bd. of Trs. of IN Laborers' Pension Fund" on Justia Law

USCA is a non-profit national civic league with approximately 27,000 members that devotes itself to conservative values and opposes efforts of the federal government to interfere with market processes. Some of USCA’s uninsured members object to the purchase of private health insurance because they do not believe in the effectiveness of traditional medicine, prefer alternative and integrative medicine, or prefer to focus on preventative care that is not covered by traditional health insurance policies. Two individual plaintiffs do not have, nor do they wish to acquire, health insurance, but they are not exempt from the Patient Protection and Affordable Care Act’s individual mandate, 26 U.S.C. 5000A. They challenged the mandate as violating the Commerce Clause, rights to freedom of expressive and intimate association, rights to liberty, and rights to privacy. The district court dismissed in part, without substantive analysis, holding that plaintiffs failed to satisfy the “plausibility standard” and entered summary judgment on the Commerce Clause challenge. The Sixth Circuit affirmed, stating that the Supreme Court’s opinion in National Federation of Independent Business v. Sebelius controls the outcome on the Commerce Clause count and the remaining constitutional claims were correctly dismissed for failure to state a claim. View "U.S. Citizens Ass'n v. Sebelius" on Justia Law