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September 29, 2014

ERISA-Ninth Circuit Holds That Decision To Prohibit Transfer Of Account Balances From One Plan To Another Did Not Violate Anti-Cutback Rule

In Andersen v. DHL Retirement Pension Plan, No. 12-36051 (9th Cir. 2014), the Ninth Circuit Court of Appeals (the "Court") dealt with the question of whether the Defendants' ("DHL") decision to eliminate Plaintiffs' right to transfer their account balances from DHL's defined contribution plan to its defined benefit plan violated the ERISA "anti-cutback" rule. This rule, found at 29 U.S.C. § 1054(g), prohibits any amendment of an employee benefits plan that would reduce a participant's "accrued benefit."

In this case, prior to the amendment challenged in this case, the Plaintiff's, who were participants in an individual account profit sharing plan at DHL (the "Profit Sharing Plan"), could transfer the funds from their Profit Sharing Plan accounts to the defined benefit retirement plan in which they also participated at DHL (the "Retirement Plan"). The Retirement Plan would offset a participant's benefit under that plan by his or her Profit Sharing Plan account balance. As a result, the transfer option, if exercised, provided increased funds for the participant under the Retirement Plan, but also reduced the Profit Sharing Account balance to zero, so that there was no offset. As such, the transfer could work to the participant's advantage. However, DHL amended the Retirement Plan to prohibit the transfers, and this suit ensued.

In analyzing the case, the Court concluded that the amendment to the Retirement Plan eliminating the transfer option did not violate the anti-cutback rule. There is no reduction is a participant's accrued benefit. The amount of the accrued benefit is determined by formula in Section 4.01 of the Retirement Plan. The amendment did not affect this formula. Under that formula, a participant's accrued benefit is, and always has been, calculated on the basis of a participant's final average compensation and years of service, with an offset for an attributed annuity amount based on the participant's account balance, if any, in the Profit Sharing Plan. The transfer option eliminated was in Section 7.11, and that Section was not part of a participant's accrued benefit. The Court noted that the anti-cutback rule prohibits the elimination of an optional form of benefit (29 U.S.C. § 1054(g)(2)). But the Court reasoned that the only plan feature eliminated was the Retirement Plan provision under which transfers were accepted, and IRS regulations under the anti-cutback rule permit elimination of this type of feature.

September 17, 2014

ERISA-Sixth Circuit Upholds Grant Of Benefits, But Not Imposition Of Penalties, For Failure To Provide Benefits For Treatment For Alcohol Addiction

In Butler v. United Healthcare of Tennessee, Inc., No. 13-6446 (6th Cir. 2014), the following obtained. More than nine years ago, the plaintiff, Janie Butler ("Janie"), checked into a substance-abuse treatment facility to obtain inpatient rehabilitation for her alcohol addiction. She sought coverage for the treatment through her husband's employer-issued ERISA plan run by the defendant, United Healthcare of Tennessee, Inc. ("United"). United denied treatment, deeming it medically unnecessary. After seven years' worth of internal reviews, trips to the district court and remands to the plan for reconsideration, the district court decided that enough was enough. It held that United had acted arbitrarily and capriciously in continuing to deny the requested coverage. And it awarded John Butler (her then-husband and the assignee of Janie's plan benefits) the cost of the requested benefits plus prejudgment interest and statutory penalties. United objects to the decision to grant benefits and to the order to pay penalties.

Upon reviewing the case, the Court affirmed the grant of benefits, but reversed the penalty award. Why? As to the benefits, the Court said that Janie obviously qualified for rehabilitation benefits under United's residential-rehabilitation guideline, which grants residential-rehabilitation benefits to insured individuals with a "[h]istory of continued and severe substance abuse despite appropriate motivation and recent treatment in an intensive outpatient . . . program." The Court concluded that United's denial of these benefits is a clear abuse of discretion.

As to the penalties, the Court noted that the district court had awarded statutory penalties to John Butler, reasoning that ERISA allows penalties of "up to $100 a day" if the plan "administrator" "fails or refuses to comply with a request for any information" that the statute requires the administrator to provide. See 29 U.S.C. § 1132(c)(1)(B). However, since United is not the "administrator" of the plan, that was a mistake. The plan did not name an administrator, so under ERISA the employer is treated as being the "administrator". Further, John Butler did not allege a violation of section 1132 (the alleged violation being of section 1133), so that the $100/day penalty cannot apply.

September 3, 2014

ERISA-Tenth Circuit Holds That Suit For Disability Benefits Is Barred Due To Failure To Exhaust Administrative Remedies

In Holmes v. Colorado Coalition For The Homeless Long Term Disability Plan, No. 13-1175 (10th Cir. 2014), the plaintiff, Lucrecia Carpio Holmes ("Ms. Holmes"), appeals the district court's ruling that her claim for disability benefits under ERISA is barred due to her failure to exhaust administrative remedies.

In this case, Ms. Holmes is a former employee of the Colorado Coalition for the Homeless (the "Coalition") and participated in an employee benefits plan funded, in part, by a disability insurance policy through Union Security Insurance Company ("Union Security). While employed by the Coalition, Ms. Holmes presented with a number of medical conditions, including breast cancer, cataplexy, apnea, blackouts, diabetes, carpal tunnel syndrome, and neuropathy. As a result, she filed a claim for disability benefits with Union Security on March 10, 2005. Union Security sent written notification to Ms. Holmes on May 27, 2005 that it had denied her claim because she failed to prove she was disabled as defined by the Policy. The denial letter included an explanation of Ms. Holmes's right to internal review of the decision and attached a copy of a Group Claim Denial Review Procedure (the "Denial Review Procedure"), which describes a two-level review process.

On November 21, 2005, in accordance with the Denial Review Procedure, Ms. Holmes filed a request for review of the denial (the first-level review). Union Security issued a decision on the first-level review 137 days later on April 7, 2006, when it informed Ms. Holmes in writing that it had affirmed the denial of benefits. Union Security's April 7, 2006, letter contained a second copy of the Denial Review Procedure, which informed Ms. Holmes that she may request another review of Union Security's decision, and that this second-level review is the final level of administrative review available. The Denial Review Procedure further states that if Ms. Holmes's claim is denied as part of the second-level review, she will have a right to bring a civil action. Rather than filing the second-level appeal, on April 28, 2008, she filed this suit.

In analyzing the case, the Tenth Circuit Court of Appeals (the "Court") said, first, that the plan document specifically authorized Union Security to advise Ms. Holmes of further appeal rights, which could include a second-level review. Next, the record shows that Union Security advised Ms. Holmes of her further appeal rights by supplying her with a copy of the Denial Review Procedures. The summary plan description (the "SPD") here did not discuss the second-level appeal, but, under the Supreme Court's decision in Amara, the SPD is not a part of the plan, and Ms. Holmes was not otherwise prejudiced by the failings of the SPD. Finally, based on the plan and the additional terms authorized by it, and the court-created requirement of exhaustion of internal claim procedures under ERISA, the Court concluded that Ms. Holmes was required to seek a second-level review before bringing this suit. Accordingly, the Court affirmed the district court's decision.

August 27, 2014

ERISA-Ninth Circuit Holds That Plan Administrator Abused Its Discretion In Refusing To Pay For More Than Three Weeks Of Inpatient Hospital Treatment

In Pacific Shores Hospital v. United Behavioral Health, No. 12-55210 (9th Cir. 2014), an employee of Wells Fargo, whom the Court called Jane Jones, was covered under the Wells Fargo & Company Health Plan (the "Plan"), governed by ERISA. United Behavioral Health ("UBH") is a third-party claims administrator of the Plan. Jones was admitted to Pacific Shores Hospital ("PSH") for acute inpatient treatment for severe anorexia nervosa. UBH refused to pay for more than three weeks of inpatient hospital treatment. UBH based its refusal in substantial part on mischaracterizations of Jones's medical history and condition. PSH continued to provide inpatient treatment to Jones after UBH refused to pay. Jones assigned to PSH her rights to payment under the Plan. PSH sued the Plan and UBH, seeking payment for the additional days of inpatient treatment.

In analyzing the case, the Ninth Circuit Court of Appeals (the "Court"), concluded that that UBH abused its discretion in refusing to pay for these days of treatment, and the Court therefore overturned its decision to pay for more than the three weeks of treatment. Why did the Court reach this conclusion?

The Court reviewed UBH's denial of benefits for abuse of discretion, since the Plan had unambiguously granted discretion to UBH. However, the Court said that it was "painfully apparent" that UBH did not follow procedures appropriate to Jones's case. No PSH hospital records were ever put into the administrative record. No UBH doctor or other claims administrator ever examined Jones. Rather UBH's decision was based entirely on telephone conversations and voicemail messages, and factual errors by certain evaluating doctors.

The Court said, further, that UBH owed a fiduciary duty to Jones under ERISA. UBH fell far short of fulfilling this duty. Dr. Zucker, UBH's primary decisionmaker, made a number of critical factual errors. Dr. Center, as an ostensibly independent evaluator, made additional critical factual errors. Dr. Barnard, UBH's final decisionmaker, stated that he arrived at his decision to deny benefits "after fully investigating the substance of the appeal." He then rubberstamped Dr. Center's conclusions. There was a striking lack of care by Drs. Zucker, Center, and Barnard, resulting in the obvious errors. What is worse, the errors are not randomly distributed. All of the errors support denial of payment; none supports payment. The unhappy fact is that UBH acted as a fiduciary in name only, abusing the discretion with which it had been entrusted. Therefore, reviewing the case for abuse of discretion, the Court concluded that UBH improperly denied benefits under the Plan in violation of its fiduciary duty under ERISA.

August 26, 2014

ERISA-Sixth Circuit Holds That Michigan State Law Which Taxes Claims Paid By, And Imposes Reporting And Other Requirements On, Self-Insured Health Plans Is Not Preempted By ERISA

In Self-Insurance Institute of America, Inc. v. Snyder, No. 12-2264 (6th Cir. 2014), the plaintiff, Self-Insurance Institute of America, Inc. ("SIIA"), represents various sponsors and administrators of self-funded ERISA benefit plans, which it claims are affected by Michigan's Health Insurance Claims Assessment Act (the "Act"). SIIA argues, among other things, that ERISA's express-preemption provision, 29 U.S.C. § 1144(a), prohibits the application of the Act to ERISA-covered entities.

In analyzing the case, the Sixth Circuit Court of Appeals (the "Court") held that the Act escapes ERISA preemption. The Court said, first, that the Act functions by imposing a one-percent tax on all "paid claims" by "carriers" or "third party administrators" to healthcare providers for services rendered in Michigan for Michigan residents."Carriers" include sponsors of "group health plans" subject to ERISA. On top of the tax, every carrier and third-party administrator paying the tax must submit quarterly returns with the Michigan Department of the Treasury and keep accurate and complete records and pertinent documents as required by the Department. Every carrier and third-party administrator must also develop and implement a methodology by which it will collect the tax subject to several conditions.

The Court said, next, that ERISA supersedes any and all State laws insofar as they relate to any employee benefit plan subject to ERISA. 29 U.S.C. § 1144(a). However, the Court found that the Act does not "relate to" any such plan, because the Act does not: (1) interfere with plan administration (the Act does not require a plan administrator to change how it administers the plan at all), (2) create inappropriate administrative burdens (despite requiring the returns and records, since those are not the plan's core functions) or (3) through its residency requirement, interfere with the relationship between the plan and its participants (even though the plan may be required to collect some additional information from participants). As such, ERISA does not preempt the Act.

August 21, 2014

ERISA-Fourth Circuit Expresses Its View On Assessing Liability For Breach Of Duty Of Prudence When Liquidating A Plan Investment

Tatum v. RJR Pension Investment Committee, No. 13-1360 (4th Cir. 2014) involved an appeal from a judgment in favor of R.J. Reynolds Tobacco Company and R.J. Reynolds Tobacco Holdings, Inc. (collectively "RJR"). Richard Tatum brought this suit on behalf of himself and other participants in RJR's 401(k) retirement savings plan (collectively "the participants"). He alleges that RJR breached its fiduciary duties under ERISA, when it liquidated two funds held by the plan on an arbitrary timeline without conducting a thorough investigation, thereby causing a substantial loss to the plan.

After a bench trial, the district court found that RJR did indeed breach its fiduciary duty of procedural prudence and so bore the burden of proving that this breach did not cause loss to the plan participants. But the court concluded that RJR met this burden by establishing that a reasonable and prudent fiduciary could have made the same decision after performing a proper investigation. In analyzing the case, the Fourth Circuit Court of Appeals (the "Court") affirmed the district court's holdings that RJR breached its duty of procedural prudence, in that RJR failed to engage in a prudent decision-making process, and therefore bore the burden of proof as to causation. But, because the Court concluded the district court then failed to apply the correct legal standard in assessing RJR's liability, the Court reversed its judgment and remanded the case back to the district court.

What did the Court say about the correct legal standard for assessing liability? The Court said that, to carry its burden and avoid liability for loss, RJR had to prove that despite its imprudent decision-making process, its ultimate investment decision was "objectively prudent," that is, a hypothetical prudent fiduciary would have made the same decision anyway. In making this determination, a court must consider all relevant evidence, including-in this case- the timing of the divestment.

August 20, 2014

ERISA-Sixth Circuit Rules That An Employer Cannot Bring Suit Against Trustees Of A Multiemployer Plan For Negligent Management

In DiGeronimo Aggregates, LLC v. Zemla, No. 12-2095 (6th Cir. Aug. 14, 2014), the plaintiff, an employer who contributes to a multiemployer pension plan governed by ERISA, filed a complaint against defendants, the trustees of that plan, alleging that they negligently managed the plan, causing plaintiff to suffer an increased withdrawal liability when a majority of contributing employers withdrew from the plan. The district court granted defendants' Rule 12(b)(6) motion to dismiss, holding that there was no substantive basis for plaintiff's negligence claim in any section of ERISA or under the federal common law.

After reviewing the case, the Sixth Circuit Court of Appeals (the "Court") said that it agreed with the district court. The plaintiff brings a claim of negligence. The Court said that, acknowledging that a negligence claim is not authorized by any section of ERISA, the plaintiff urges us to utilize our lawmaking powers under the federal common law to create a new negligence claim in favor of contributing employers.

The Court said, further, that is has previously held that the Court's authority to create federal common law in this area is restricted to instances in which: (1) ERISA is silent or ambiguous; (2) there is an awkward gap in the statutory scheme; or (3) federal common law is essential to the promotion of fundamental ERISA policies. Here, none of these conditions are met. Rather, because Congress has established an extensive statutory framework and expressly announced its intention to occupy the field of private-sector pensions, and because the Court does not lightly create additional rights under the federal common law given these circumstances, the Court concluded that a contributing employer to a multiemployer pension plan has no cause of action against plan trustees for negligent management under the federal common law of ERISA pension plans. As such, the Court affirmed the district court's judgment.

August 14, 2014

ERISA-Third Circuit Rules That Plaintiffs' Supplemental Coverage Is Part Of An ERISA Plan, So That State Law Claims Including Fraud Are Preempted By ERISA

In Menkes v. Prudential Insurance Company of America, No. 13-1408 (3rd Cir. 2014), the two plaintiffs were appealing the district court's dismissal of their complaint for failure to state a claim.

In this case, the plaintiffs were employed by defense contractor defendant Qinetiq to work on a military base in Kirkuk, Iraq in 2008. As employees, the plaintiffs were automatically enrolled in Qinetiq's ERISA-covered Basic Long Term Disability, Basic Life, and Accidental Death and Dismemberment insurance policies (the "Basic Policies"). These policies were established pursuant to a single group contract with the Prudential Insurance Company of North America ("Prudential") and Qinetiq paid the premiums for each of these policies on behalf of its employees. Both plaintiffs also purchased, from Prudential, supplemental long term disability insurance coverage, and one plaintiff (Menkes) purchased supplemental accidental death and dismemberment insurance coverage, to augment their benefits under the Basic Policies, paying the premiums for this coverage out of their own funds (collectively, the "Supplemental Coverage"). The Basic Policies and Supplemental Coverage were explained in a single booklet (a "Booklet") and summary plan description ("SPD") for each type of insurance The Booklets and SPDs contained an exclusion for injuries occurring during war.

After Menkes filed a claim for disability benefits which Prudential rejected, and this suit ensued. One of the claims made by the plaintiffs was that Prudential fraudulently induced them to buy the Supplemental Coverage, knowing that any claim they filed would likely be subject to the war exclusion clauses because their place of employment was in a war zone in Iraq. Other state law claims were asserted. They wanted a return of premium for this coverage and punitive damages.

The District Court dismissed the suit in its entirety. It held that the Supplemental Coverage was governed by ERISA and could not be unbundled from the Basic Policies. Viewing the Basic Policies and Supplemental Coverage as closely related component parts of a single plan, it held that all of the plaintiffs' claim of fraud, and the other state law claims they made, were expressly preempted by ERISA's broad preemption clause, § 514(a). In the alternative, it held that the plaintiffs' claims were preempted by § 502(a) of ERISA because the causes of action that the plaintiffs asserted conflicted with ERISA's exclusive civil enforcement scheme. - The Third Circuit Court of Appeals agreed with this analysis, and therefore affirmed the district court's decision.

August 13, 2014

ERISA-Sixth Circuit Holds That A Letter From The Plan Administrator Denying A Benefit Must Include Information On The Time Frame For Filing Suit To Challenge The Denial

In Moyer v. Metropolitan Life Insurance Company, No. 13-1396 (6th Cir. 2014), Joseph Moyer ("Moyer"), a participant in a plan governed by ERISA, appeals the district court's dismissal for untimeliness of his action against the plan's claim administrator, Metropolitan Life Insurance Company ("MetLife"), seeking recovery of unpaid plan benefits.

In this case, as an employee of Solvay America, Inc., Moyer participated in Solvay's ERISA-governed Long Term Disability Plan (the "Plan"). When Moyer applied for disability benefits in 2005, MetLife initially approved his claim, but reversed its decision in 2007 after determining that Moyer retained the physical capacity to perform work other than his former job. Moyer filed an administrative appeal, and MetLife affirmed the revocation of benefits on June 20, 2008. Moyer's adverse benefit determination letter included notice of the right to judicial review but failed to include notice that a three-year contractual time limit applied to judicial review. The Plan's summary plan description (the "SPD") failed to provide notice of either Moyer's right to judicial review or the applicable time limit for initiating judicial review.

On February 20, 2012, Moyer sued MetLife, seeking recovery of unpaid plan benefits under 29 U.S.C. § 1132(a)(1)(B). MetLife moved to dismiss, arguing that the Plan's three-year limitations period barred Moyer's claim. The district court agreed, noting that the plan documents--which were not sent to plan participants unless requested--stated in the Claims Procedure section of the plan that there was a three-year limitations period for filing suit. It concluded that MetLife provided Moyer with constructive notice of the contractual time limit for judicial review. Moyer now appeals, requesting equitable tolling.

In analyzing the case, the Eighth Circuit Court of Appeals (the "Court") said that courts uphold contractual limitations periods embodied in ERISA plans as long as the period qualifies as "reasonable." However,the three year time limit, found in the Plan document, for seeking judicial review was not provided to Moyer in the letter revoking his benefits or in the SPD. The Court concluded that, under ERISA's claim procedure (29 U.S.C. § 1133) and the underlying DOL regulations, this time limit should have been included in this letter. The failure to include the time limit violates ERISA, and Moyer is entitled to a judicial review of the benefit denial. Having so concluded, the Court did not need to reach the issue of whether the time limit should have been included in the SPD. Accordingly, the Court reversed the district court's holding, and remanded the case back to the district court to consider Moyer's judicial appeal of his adverse benefit determinatio

August 12, 2014

ERISA-Eighth Circuit Holds That Surcharge, Reformation And Equitable Estoppel Could Be Available To Remedy The Fiduciary's Failure To Provide An SPD

In Silva v. Metropolitan Life Insurance Company, No. 13-2233 (8th Cir. 2014), Abel Silva ("Abel") died on June 27, 2010. His father, Salvador Silva ("Silva"), sought to recover the benefits of Abel's life insurance policy (the policy being the "Plan"). The insurer denied Silva's claim, asserting that Abel did not actually have a policy because he had not provided required paperwork. Silva brought suit against Abel's employer, Savvis Communications Corporation ("Savvis"), and the insurer and plan fiduciary, Metropolitan Life Insurance Company ("MetLife"), under ERISA. The district court denied relief, and Silva appeals.

In analyzing the case, the Eighth Circuit Court of Appeals (the "Court") noted that the district court granted summary judgment to the defendants because it found that Silva was not entitled to benefits under the Plan. Section 1132(a)(1)(B) of ERISA allows Silva to bring a civil action "to recover benefits due to him under the terms of his plan." The defendants argue that Silva is not entitled to "recover benefits under the terms of his plan" because the terms of the Plan required Abel to submit evidence of insurability as a late enrollee. Silva argues that § 1132(a)(1)(B) entitles him to benefits owed under the Plan. To succeed, Silva must show that MetLife's determination that he had not provided "evidence of insurability" was an abuse of discretion (due to its discretion as plan administrator, with somewhat less deference because of conflict as plan administrator and payor). Since it is not clear as to whether there has been an abuse of discretion, the Court reversed the case and remanded Silva's § 1132(a)(1)(B) claim to the district court for further proceedings.

The Court also faced the question as to whether Silva could add a claim for equitable relief under section 1132(a)(3) of ERISA, based on fiduciary failure to provide a summary plan description (the "SPD")that explained the Plan's enrollment procedures. The district court did not allow this addition, finding that the § 1132(a)(3) claim was futile because Silva sought money damages ($429,000 in policy benefits), rather than equitable relief, which the district court concluded was unavailable under that section of the statute. The Court ruled that the failure to provide the SPD was a breach of fiduciary duty. But does this wrong have a remedy? Under the Supreme Court's decision in Amara, the remedy of surcharge could be available, to provide relief in the form of monetary "compensation" for a loss resulting from a trustee's breach of duty, or to prevent the trustee's unjust enrichment. The remedy is available if the plan participant shows harm resulting from the plan administrator's breach of a fiduciary duty. Since, under the facts alleged, Silva could make such a showing, the Court reversed the district court's determination that a claim under § 1132(a)(3) against the defendants would be futile. The Court also stated, in remanding the case back to the district court, that the remedies of reformation and equitable estoppel could be available under Amara.

August 11, 2014

ERISA-Second Circuit Rules that Claims By A Medical Fund Against Another Fund For Unpaid Contributions Are State Law Breach-Of-Contract Claims, Rather Than Claims Under ERISA

In Silverman, Trustee of the Union Mutual Medical Fund v. Crowley, Docket Nos. 13‐392‐cv(L), 13‐1175‐cv(XAP) (2nd Cir. 2014), the Teamsters Local 210 Affiliated Health and Insurance Fund (the "210 Fund") and its trustees appeal from a judgment of the district court, which awarded approximately $2.5 million to the Union Mutual Medical Fund ("UMM Fund") for unpaid ERISA plan contributions.

In analyzing the case, the Second Circuit Court of Appeals (the "Court") said that, since the 210 Fund was not obligated to contribute funds to the UMM Fund under the terms of an ERISA plan (such contributions were required under a collective bargaining agreement, which is not an ERISA plan), the district court lacked subject matter jurisdiction under ERISA over the claims on which the UMM Fund prevailed. However, because these claims can be construed as state law breach‐of‐contract claims, the Court vacated and remanded the case back to the district court to decide, in the first instance, whether to exercise supplemental jurisdiction and decide the claims under this alternative theory.

August 5, 2014

ERISA-Seventh Circuit Rules That Companies, Which Were Under Common Control With An Employer That Incurred Withdrawal Liability, Are Jointly and Severally Liable For The Withdrawal Liability

In Central States Southeast and Southwest Area Pension Fund v. CLP Venture LLC, Nos. 13-3010 and 13-3776 (7th Cir. 2014), the Seventh Circuit Court of Appeals (the "Court") was asked to determine whether the various co-defendants were under common control, and therefore are jointly and severally liable for the withdrawal liability incurred by General Warehouse, Inc. ("General Warehouse").

In this case, the Central States Pension Fund (the "Fund") had filed suit to collect withdrawal liability, totaling $1,262,568, against General Warehouse, the employer incurring the liability, as well as against GEOBEO and other businesses under common control. The parties to that litigation entered into a consent judgment, acknowledging that the named defendants were jointly and severally liable. The Fund then initiated this action to add the defendants to the group of business entities from which it can collect.

After reviewing the case, the Court found that " there is overwhelming evidence that these entities were under common control" with General Warehouse-since the entities had the requisite common ownership and were trades or businesses. The Court therefore ruled that these entities are jointly and severally liable for General Warehouse's withdrawal liability.

August 4, 2014

ERISA-Second Circuit Rules That New York Law Prohibiting Insurer Subrogation Is Not Preempted By ERISA

In Wurtz v. The Rawlings Company, LLC, No. 13‐1695‐cv (2nd Cir. 2014), the plaintiffs initially filed the complaint in this case in New York state court, seeking, among other things, to enjoin defendant insurers under N.Y. Gen. Oblig. Law § 5‐335 from obtaining reimbursement of medical benefits from plaintiffs' tort settlements (that is, to enjoin the insurers from enforcing subrogation rights to obtain the settlement amounts). The defendants removed this action to the Eastern District of New York. There, the district court granted the defendants' motion to dismiss under Rule 12(b)(6) for failure to state a claim on the basis that the plaintiffs' claims were subject to both "complete" and "express" preemption under ERISA.

Upon review, the Second Circuit Court of Appeals (the "Court") held, first, that the plaintiffs' claims do not satisfy the Supreme Court's test for being subject to complete ERISA preemption (in Aetna Health Inc. v. Davila) , which would have conferred federal subject‐matter jurisdiction. Such jurisdiction exists, however, under the Class Action Fairness Act ("CAFA"), 28 U.S.C.§ 1332(d). Accordingly, the Court then reached the merits of the express preemption defense, and concluded that N.Y. Gen. Oblig. Law § 5‐335 is saved from express preemption under ERISA § 514, 29 U.S.C. § 1144, as a law that "regulates insurance." Accordingly, the Court reversed the district court's judgment and remanded the case for further proceedings on the plaintiffs' claims.

Two points to be considered here. First, the Court ruled that the claims were not subject to complete preemption under ERISA, since-contrary to the requirements of the Supreme Court (in Davila)- the claims could not be construed as claims for benefits under ERISA section 502(a)(1)(B), and there may be independent duties, aside from those arising under ERISA or any employee benefit plan, that the defendants may have breached.

The second point is why N.Y. Gen. Oblig. Law § 5‐335 is not subject to express preemption under ERISA. This provision states that a personal injury settlement presumptively "does not include any compensation for the cost of health care
services" or other losses that "are obligated to be paid or reimbursed by a benefit provider" (such as an insurer), and that benefit providers have no "right of subrogation or reimbursement against any such settling party." ERISA expressly preempts any state law that "relate[s] to any employee benefit plan," but not if that law "regulates insurance." ERISA § 514(a)‐(b), 29 U.S.C. § 1144(a)‐(b). In this case, the N.Y. Gen. Oblig. Law § 5‐335 regulates insurance, since this provision is specifically directed toward insurers and substantially affects risk pooling between
insurers and insureds. As such, it is saved from express preemption.

July 29, 2014

ERISA-Eighth Circuit Holds That Insurer's Interpretation Of Plan's Pre-Existing Condition Is Reasonable, And Therefore Upheld The Insurer's Denial Of Long-Term Disability Benefits

In Kutten v. Sun Life Assurance Company of Canada, No. 13-2559 (8th Cir. 2014), the plaintiff, Marc Kutten ("Kutten") sued Sun Life Assurance Company of Canada ("Sun Life"), alleging that SunLife improperly denied him long-term disability ("LTD") benefits under a disability plan governed by ERISA. The district court granted Kutten's motion for summary judgment, and Sun Life appeals.

In this case, in 1994,Kutten was diagnosed with retinitis pigmentosa, a progressive eye disease that can eventually lead to blindness. Effective June 1, 2010, his company purchased a new disability policy with SunLife (the "Plan"). The Plan included an exclusion for "pre-existing conditions", defined in the Plan as a condition for which, during the 3 months prior to the Plan's effective date, the employee received medical treatment, care or services, including diagnostic measures, or took prescribed drugs or medicines for the disabling condition. On September 21, 2010, Kutten's eye condition forced him to stop working. He applied for LTD benefits under the Plan on October 6, 2010. After initially denying Kutten's claim, Sun Life concluded on appeal that Kutten was "Totally Disabled." Nevertheless, Sun Life determined that Kutten was not entitled to LTD benefits under the Plan, due to his use of vitamin A supplements at his doctor's direction being a "medical treatment" which invoked the pre-existing condition exclusion. Kutten then filed this suit, seeking the LTD benefits.

In analyzing the case, the Eighth Circuit Court of Appeals (the "Court") noted that, due to Sun Life's discretionary authority to construe the Plan's terms, the Court will review Sun Life's decision to deny the LTD benefits for abuse of discretion. It then said that this case turns on a narrow question: Was it reasonable for Sun Life to conclude that Kutten's vitamin A supplements constituted a "medical treatment"? The Court said that Sun Life offered a reasonable interpretation of the Plan, based on the purpose of the pre-existing condition exclusion and the normal understanding of what constitutes "medical treatment". As such Sun Life's conclusion as to the applicability of the pre-existing condition exclusion is reasonable. Therefore, the Court reversed the district court's summary judgment, and remanded the case for the district court to enter summary judgment in favor of Sun Life.

July 22, 2014

ERISA-Sixth Circuit Rules That Plaintiffs Are Entitled To Pension Benefits Under The Plan's Change In Control Provisions

In Adams v. Anheuser-Busch Companies, Inc., No. 13-3149 (6th Cir. 2014), the plaintiffs had brought suit against defendants Anheuser-Busch Companies, Inc. and others (collectively, "Anheuser-Busch"), in which they seek benefits under the terms of an employee benefits plan sponsored by Anheuser-Busch. They now appeal the district court's decision upholding the plan administrator's denial of their claims for benefits provided under Section 19.11(f) of the plan. That Section authorized enhanced pension benefits for plan participants whose employment with an Anheuser-Busch company is involuntarily terminated within three (3) years after a Change in Control. The district court held that the plaintiffs had not been involuntarily terminated within the meaning of Section 19.11(f), because they secured employment with a successor corporation. In analyzing the case, the Sixth Circuit Court of Appeals (the "Court") concluded that the district court's reading of Section 19.11(f) of the plan was flawed, and it reversed the district court's holding.

The Court said the following. Section 19.11(f) of the Anheuser-Busch plan states that, in the event of a "change in control," the retirement benefits of a plan participant "whose employment with the Controlled Group is involuntarily terminated within three (3) years after the Change in Control shall be determined by taking into account an additional five (5) years of Credited Service and . . . an additional five (5) years of age." In this case, the administrator concluded that "Section 19.11(f) was intended to provide an enhanced benefit to participants who suffer an actual termination or loss of employment." The district court concluded both that the language of Section 19.11(f) was ambiguous and that the administrator's interpretation was reasonable.

The Court continued by saying that the scope of the parties' disagreement is narrow: they dispute only the meaning of the phrase "involuntarily terminated." The defendants argue that the common understanding of the phrase "involuntarily terminated" requires an actual job loss, and that the plaintiffs' jobs were not "involuntarily terminated" because they continued to work uninterrupted in the same positions with the company's purchaser. The plaintiffs, on the other hand, contend that their employment with Anheuser-Busch's Controlled Group was involuntarily terminated on October 1, 2009, because, although still employed by someone, their employment with the Controlled Group was terminated, and the termination was "involuntary" because they did not choose it.

The Court concluded that a careful reading of the plan language demonstrates that the plaintiffs' interpretation of Section 19.11(f) is the only plausible interpretation. As such, the Court ruled that the district court erred in upholding the plan administrator's interpretation of Anheuser-Busch's pension-benefit plan provision at issue in this case. Accordingly, the Court reversed the judgment of the district court and remanded the case for entry of judgment in favor of the plaintiffs.