ERISA-Eighth Circuit Rules That Claim For Unpaid Health Benefits Must Be Brought By The Estate Of The Deceased Beneficiary Who Incurred The Claim, And Not By His Spouse

In Ibson v. United Healthcare Services, Inc., No. 16-3260 (8th Cir. 2017), an ongoing dispute between CeCelia Ibson and United HealthCare Services, Inc. (“UHS”) has returned to this court (the Eighth Circuit Court of Appeals or the “Court”).  After the Court decided that ERISA preempted her state-law claims, Ibson filed claims under ERISA against UHS.  The district court dismissed her complaint.  The question before the Court, now, is whether Ibson has pled a viable claim against UHS under ERISA.

Ibson was at one time a shareholder in an Iowa law firm that contracted with UHS to provide health insurance for its employees.  Ibson enrolled herself and her family, including her late husband, Jay Wagner, in her employer-sponsored UHS healthcare plan in March 2004.  In early 2008, UHS began denying claims, and until 2010, pursued recoupment actions for claims already paid.  UHS eventually paid $36,417.29 for outstanding claims.  This suit ensued, however, with Ibson alleging that UHS still owes $190,579.91 for the care Jay Wagner received.  She is seeking recovery of that amount of “unpaid benefits” under Section 502(a)(1)(B) of ERISA.

After reviewing the case, the Court said that Ibson does not have a claim to alleged unpaid benefits due under Section 502(a)(1)(B); rather, that claim must be brought by the estate of the beneficiary, Jay Wagner.  The Court also found that Ibson cannot bring this claim, in her personal capacity, for the unpaid benefits in equity under Section 502(a)(3)(B) of ERISA.  But, a restitutionary claim for premiums Ibson paid under Section 502(a)(3)(B) is potentially available to her if there was a plan violation.  Accordingly, the Court remanded the case to the district court to determine initially if there was such a plan violation and, if so, whether restitution of Ibson’s premiums is “appropriate equitable relief” under Section 502(a)(3)(B).

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