Source: https://www.lifeanddisabilitylaw.com/erisa-watch-december-21-2015/
Timestamp: 2019-04-19 10:39:59+00:00

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Happy Monday ERISA Watchers! There are two notable decisions this week. The first is Granville v. Aetna Life Insurance Co., No. 3:14-CV-00211, 2015 WL 9026025 (M.D. Pa. Dec. 15, 2015), where the court held that a denial of long-term disability benefits based on a perfunctory paper review and failure to investigate is an abuse of discretion. It is always refreshing when a court sees through the claim that a pure paper review of a disability claimant is substantial evidence supporting a claim denial. The second notable decision is Apollo Educ. Grp. Inc. v. Henry, No. CV-15-00143-PHX-DJH, __F.Supp.3d___, 2015 WL 9257027 (D. Ariz. Dec. 17, 2015), where the court dismissed a subrogation/reimbursement action against a plan participant because the relevant provision was contained only in the Summary Plan Description and not in the Master Plan Document. Although the Master Plan Document incorporated the SPD, it was otherwise silent on subrogation, and the court found this silence was a conflict with the SPD. By its own terms, the SPD states that the written instrument will control in the event of a conflict between the written instrument and the SPD and this “conflict” provision evinced a recognition that the SPD is a separate document.
I hope that everyone enjoys the holidays and is able to spend quality time with friends and family. To that end, ERISA Watch will take a brief hiatus and resume starting January 11th. This is not a goodbye, but “a see you soon.” Happy New Year!
Subrogation/reimbursement provision contained only in SPD, incorporated by the master plan document which is otherwise silent on subrogation, is not enforceable because it is in conflict with the master plan document. Apollo Educ. Grp. Inc. v. Henry, No. CV-15-00143-PHX-DJH, __F.Supp.3d___, 2015 WL 9257027 (D. Ariz. Dec. 17, 2015) (Judge Diane J. Humetewa). This matter involves a subrogation action brought by a health plan against a participant for reimbursement of medical expenses following a settlement with a third party. Plaintiffs brought suit against Defendant seeking equitable relief in the form of enforcement of their reimbursement rights under the Plan, injunctive and declaratory relief, and an order for damages in the amount of $47,930.87 for Defendant’s alleged breach of the agreement to reimburse Plaintiffs. Defendants moved to dismiss on the basis that the written instrument on the Plan does not contain any subrogation/reimbursement provision, which is only contained in the Summary Plan Description (“SPD”). Here, the Plan incorporated the SPD. Defendants also moved to dismiss on the basis that the Plan and the SPD are in conflict and that in this event the terms of the Plan control. With respect to the first argument, the court was skeptical of Defendant’s claim that under no circumstances may an SPD be incorporated into a written instrument. However, the court found that it need not decide that issue because it found that Defendant is entitled to relief based on the second argument that the written instrument and the SPD are in conflict with regard to the issue of reimbursement. The language of the SPD itself states that the written instrument “will control in the event of any conflict between the provisions of the Plan and this SPD.” The court found that if the SPD and the Master Plan Document have become one in the same through incorporation, there would be no need for a conflict provision like the one in the SPD. Thus, by including the conflict provision in their SPD, the court found that Plaintiffs implicitly recognize that the SPD retains its separateness from, and is less authoritative than, the master plan document. Because there is no reimbursement provision in the master plan document, the court held that Defendant is not required to reimburse Plaintiffs for the medical expenses paid on his child’s behalf and dismissed the action.
Court orders final approval of class action settlement against Unum alleging underpayment of long-term disability benefits. Kemp v. Unum Life Insurance Company of America, No. 14-0944, 2015 WL 8526689 (E.D. La. Dec. 11, 2015) (Judge Nannette Jolivette Brown). The court granted final settlement approval for the following Settlement Class: All current or former Humana employees who (1) received long-term disability benefits from Unum under the Policy; (2) became disabled within the meaning of the Policy between and including May 1, 2002, and October 31, 2013; (3) received Perpetuity Payments from Humana; and (4) whose long-term disability benefit payment amount was calculated without including Perpetuity Payments as Monthly Earnings as defined in the Policy. The settlement amount totals $3,738,402 and the court approved attorneys’ fees of 33.33%, or $3,738,402, reimbursement of litigation expenses of $17,878.65, and a class representative incentive award of $5,000.
Under terms of policy, insurer may require disability claimant to exhaust all administrative appeals for SSDI benefits before paying estimated benefit offsets. McGlynn v. Reliance Standard Life Insurance Company, No. 3:14-CV-2033, 2015 WL 9182871 (M.D. Pa. Dec. 17, 2015) (Judge A. Richard Caputo). In dispute in this case is whether Reliance Standard was obligated under the terms of the long-term disability policy to reimburse to Plaintiff estimated Social Security Disability Insurance (“SSDI”) benefit offsets after Plaintiff’s request for SSDI benefits was denied but not denied at the highest level without ability for further appeal. Plaintiff argued that the policy language requires only expiration of the social security appeal period before the estimated amount is paid and that the policy language does not require an insured to endlessly pursue a possibly frivolous appeal to the “highest level” in the federal court system. Plaintiff did not appeal her SSDI denial. The court found that the policy language was ambiguous but that Reliance’s interpretation requiring Plaintiff to exhaust all administrative appeals before recovering the estimated offset was reasonable and not an abuse of discretion. The court denied Plaintiff’s motion for judgment on the pleadings and granted Reliance Standard’s motion for summary judgment.
Denial of LTD benefits based on a perfunctory paper review and failure to investigate is an abuse of discretion. Granville v. Aetna Life Insurance Co., No. 3:14-CV-00211, 2015 WL 9026025 (M.D. Pa. Dec. 15, 2015) (Judge Robert D. Mariani). The court granted Plaintiff’s motion for summary judgment on her claim seeking long-term disability benefits. The court found that Aetna engaged in multiple procedural irregularities, including conducting a self-serving paper review of the medical files based on the incorrect disability standard, relatedly relying on the opinion of a non-treating, non-examining physician without reason, and denying benefits based on inadequate information and lax investigatory procedures, as evidenced by Aetna’s decision not to pursue an independent medical examination and its failure to analyze the specific requirements of Plaintiff’s own occupation. The court found that these irregularities compounded each other throughout the review and appeal of Plaintiff’s administrative claim and constituted an arbitrary and capricious denial of benefits. Here, Plaintiff’s claim is based on objective evidence, specifically multilevel degenerative disc changes at the C4/C5 with severe changes at C6/C7 accompanied by a right posterior disc protrusion with moderate to severe narrowing of the right neural foramina at that level and severe spinal stenosis. The court found that nothing in Aetna’s review indicates in any way that it challenges the existence of these significant limitations which Plaintiff has been objectively shown to possess. Aetna’s decision to deny Plaintiff benefits on the strength of a perfunctory paper review, coupled with the absence of any effort on the part of Aetna to undertake any other action to support its decision, requires that its denial of Plaintiff’s claim be deemed arbitrary and capricious.
District court erred by imposing “treating physician” rule in review of denied disability claim. Schiro v. Office Depot, Inc., No. 15-30066, __Fed.Appx.___, 2015 WL 9147748 (5th Cir. Dec. 16, 2015) (Before JONES, SMITH, and SOUTHWICK, Circuit Judges). The Fifth Circuit reversed the district court’s grant of summary judgment in favor of Schiro. The district court concluded that Sedgwick had abused its discretion by relying on its internal medical staff’s opinions rather than Schiro’s treating physicians. The Fifth Circuit held that the denial was supported by substantial evidence, and the district court imposed a “treating physician” rule that is inappropriate in the context of plans covered by ERISA. The court explained that under proper abuse-of-discretion review, Sedgwick was not required to explain why it credited its internal opinions over those of the treating physicians, nor was Sedgwick’s evidence less substantial in light of conflicting opinions offered by the treating physicians. The court found that the district court did not conduct a proper abuse-of-discretion review when it imposed such a burden.
Court denies disability claimant relief from local rule prohibiting disclosure of court-sponsored mediation communications. Jones v. Life Insurance Company of North America, No. 08-CV-03971-RMW, 2015 WL 8753996 (N.D. Cal. Dec. 15, 2015) (Judge Ronald M. Whyte). In matter challenging LINA’s offset of dependent Social Security disability insurance benefits, Plaintiff sought permission to disclose to the court for evidentiary purposes things that happened and things that were said in District Court and Ninth Circuit mediation, as well as Defendants’ mediation brief. The court denied Plaintiff’s motion from ADR confidentiality. It found that Plaintiff did not meet certain narrow exceptions to the general prohibition on disclosure of information from court-sponsored mediation as set forth in ADR Local Rule 6-12. The court rejected Plaintiff’s argument that ERISA requires disclosure of mediation communications, finding that the mediation exchanges are not part of the administrative record simply because the parties may have discussed administrative proceedings at mediation. The court found that no manifest injustice would result by not permitting Plaintiff to disclose the mediation communications, distinguishing this case from Barnes v. AT&T Pension Benefit Plan-Non-Bargained Program, 963 F.Supp.2d 950 (N.D. Cal 2013), where the court had permitted consideration of an early neural evaluation for purposes of a collateral issue dealing with notice as it affected attorneys’ fees. Lastly, the court found that disclosure for purposes of impeachment would undermine the policy goal of Federal Rule of Evidence 408-encouraging settlement.
Plaintiff did not provide facts that show he has a colorable procedural or bias claim such that he is entitled to discovery. Corey v. Sedgwick Claims Mgmt. Servs., et al., No. 1:15 CV 1736, 2015 WL 9206490 (N.D. Ohio Dec. 17, 2015) (Judge Patricia A. Gaughan). Plaintiff moved to compel discovery on conflict of interest with respect to his denied claim for disability benefits. Specifically, he claimed that it was unclear who actually made the decision to deny his claim, under what authority, and based on what evidence. He also claimed that it was unclear whether Defendants followed Plan protocol for allowing him to bring his long term disability claim. Finally, Plaintiff claimed that portions of the Administrative Record are redacted as “Restricted Proprietary Information.” The court denied Plaintiff’s motion, finding that he offered no evidence to suggest that the Plan’s decision was the result of bias, conflict, or procedural irregularity such that discovery is warranted in this case: 1) nothing in the final denial letter suggests that Defendants’ actions were based on any irregularities; 2) the denial letter is also clear as to who made the final decision to deny plaintiff benefits and identifies what evidence the Committee relied on in making the determination to deny benefits, and that evidence is a part of the Administrative Record; 3) Defendants provided plaintiff and the Court with a copy of the medical review referenced in the denial letter, and Plaintiff has produced no evidence that indicates Defendants deliberately withheld this or any other medical review. The court also found that no discovery is necessary on the long term disability claim because the Plan documents define all Plan procedures and Plaintiff can rely on the evidence in the Administrative Record to support this claim. Finally, the court found that Defendants’ act of marking some documents as “proprietary information” does not show that Defendants acted out of bias or procedural irregularity.
Breach of contract claim for lump sum benefit under pension plan is completely preempted by ERISA. Keever v. NCR Pension Plan, et al., No. 3:15-CV-196, 2015 WL 9255342 (S.D. Ohio Dec. 17, 2015) (Judge Walter H. Rice). The court found that Plaintiffs’ lawsuit seeking to recover the lump sum benefit that their mother elected to receive in lieu of monthly payments under the NCR Pension Plan, which is an ERISA-regulated employee benefit plan, is completely preempted by ERISA. The court further found that under the circumstances presented here, it cannot be said that the legal duty that was allegedly breached, i.e., NCR Pension Plan’s duty to pay the lump sum benefit, is “independent of ERISA or the plan terms.” Although Plaintiffs contended that they lack standing to bring an ERISA claim, the court found that they do have standing to pursue a claim for benefits since the mother was a beneficiary as defined by ERISA and her estate now stands in her shoes and is entitled to pursue a claim. Regardless, the court explained that even if Plaintiffs lacked statutory standing to pursue a claim for benefits that this would not necessarily deprive the federal court of subject matter jurisdiction.
State law negligence claim against paper reviewing doctors properly removed due to complete preemption. Hackney v. AllMed Healthcare Management, Inc., No. 3:15-CV-00075-GFVT, 2015 WL 8682184 (E.D. Ky. Dec. 11, 2015) (Judge Gregory F. Van Tatenhove). Plaintiff initially filed a Complaint in Shelby Circuit Court “relating to Defendant AllMed Healthcare Management Inc.’s actions in rendering an unlicensed medical opinion concerning Plaintiff.” Specifically, Plaintiff filed for disability income benefits payable under a long-term insurance policy that is governed by ERISA. At the insurer’s request, AllMed agreed to provide a written medical opinion concerning Plaintiff’s physical condition. Robert J. Cooper, a contract employee of AllMed, and Skip Freeman, AllMed’s medical director, participated in drafting and issuing the medical opinion ultimately sent to the disability insurer. Neither Cooper nor Freeman were licensed to practice medicine in Kentucky under KRS § 311.560.1. AllMed filed a notice of removal, asserting that the Complaint is completely preempted by ERISA. The court denied Plaintiff’s motion to remand, finding that his claim against AllMed for negligence per se is really a “suit complaining of a denial of coverage for medical care, where the individual is entitled to such coverage only because of the terms of an ERISA-regulated employee benefit plan.” Further, the court found that Plaintiff does not allege the violation of any legal duty independent of ERISA or of the plan terms. Rather, the state law claim for negligence arises solely in the context of AllMed’s review of Plaintiff’s claim file, which, in turn, arises solely in the context of Lincoln National’s review of his claim for disability benefits under ERISA. Plaintiff would not have a claim against AllMed but for his claim for disability benefits under ERISA.
Lawsuit seeking damages related to misrepresentation about post-termination health insurance coverage not preempted by ERISA. Lamonica v. Brown Nursing Home, LLC, No. 3:15CV326-SRW, 2015 WL 9008449 (M.D. Ala. Dec. 15, 2015) (Magistrate Judge Susan Russ Walker). Defendant removed Plaintiff’s lawsuit arising out of Defendant’s termination of her employment and subsequent representations about her health insurance on the basis of complete ERISA preemption. Plaintiff moved to remand and for attorneys’ fees, stating in her motion to remand that the gravamen of her complaint is not that she was wrongfully denied benefits under her employer-provided health insurance plan, but that defendant Brown lied to her about when her insurance coverage would be terminated. Plaintiff does not seek to recover plan benefits, but rather, compensation for damages she suffered as a result of Defendant’s alleged misrepresentations, including, but not limited to, medical expenses she incurred for treatment of the mental anguish and stress she experienced as a result of defendant Brown’s alleged misrepresentations. The court granted Plaintiff’s motion to remand, finding that Brown did not meet its burden of demonstrating that her claims could have been brought under ERISA § 502(a) or that Plaintiff’s claims do not implicate a duty independent of ERISA.
Exhaustion of administrative remedies is excused and would have been futile. Knigge v. the Dorothy Prusek 401(k) Plan, et al., No. 14-CV-0542, 2015 WL 8986326 (N.D. Ill. Dec. 16, 2015) (Judge Sharon Johnson Coleman). In this case Plaintiff alleged that Defendants failed to deposit portions of Plaintiff’s elected deferred compensation into the 401(k) plan and did not make their employer contribution to the Plan after 2005. In 2012, upon learning that the Plan was being terminated because of the inactivity of Defendants, Plaintiff asked Prusek to reinstate the plan and deposit the missing contributions, but Prusek refused to do so. Defendants moved to dismiss based on failure to exhaust administrative remedies. The court denied Defendants’ motion, finding that exhaustion was excused because Plaintiff was denied meaningful access to review procedures as she was never provided copies of Plan documents and was not informed how to pursue an appeal. Although Defendants attempted to introduce contradictory evidence, the court found Plaintiff’s allegation that she was not informed of the available review procedures as adequate to survive the motion to dismiss. Further, exhaustion would have been futile since the decisionmaker, a solo practitioner, would be the ultimate arbitrator of any administrative proceeding and would be reviewing her own prior refusal to remedy the situation.
Retirement plan’s conservative interpretation of maximum contribution limits is not arbitrary and capricious. Gerber v. Ohio N. Univ., et. al, No. 3:14 CV 2763, 2015 WL 9206584 (N.D. Ohio Dec. 17, 2015) (Judge Jack Zouhary). The pro se plaintiff challenged ONU’s interpretation of the ONU’s Defined Contribution Retirement Plan’s maximum contribution limits for the years 2002-06, contending that he was not allowed to make the maximum voluntary contribution. The Plan required participants to defer 7.5% of their compensation while also allowing voluntary contributions. The Plan stated a participant’s total contributions could not exceed the limits set forth in 26 U.S.C. §§ 415 and 402(g). During the period in question, the Plan did not distinguish between mandatory and elective deferrals in calculating the maximum amount, combining them to determine the 402(g) limit, which it did so in part based on advice from TIAA-CREF. The IRS did an audit of the Plan per Plaintiff’s urging and it concluded that “reducing allowable elective deferrals by the amount of mandatory contributions did not result in any violation of IRC section 403(b) for the 2002 through 2006 tax years.” The court determined that ONU’s conservative interpretation of the limits was reasonable. Further, Plaintiff’s dispute concerning ONU’s interpretation made years before was basically a breach of fiduciary duty claim under the guise of a denial of benefits claim and the statute of limitations for such a claim has long since passed. The court denied Plaintiff’s motion to amend his complaint to include a breach of fiduciary duty claim and to supplement the administrative record with information that the court deemed either irrelevant or duplicative of documents already in the administrative record.
Fund abused its discretion in not recognizing terms of posthumous QDRO. Cingrani v. Sheet Metal Workers’ Local No. 73 Pension Fund, No. 15 C 6430, 2015 WL 8780620 (N.D. Ill. Dec. 15, 2015) (Judge Harry D. Leinenweber). Plaintiff filed a motion for judgment on the pleadings on his ERISA claim for benefits challenging the Fund’s decision to revert back to the Plan his ex-spouse’s 50% interest in his pension benefit where she died before he retired, the QDRO was silent as to what would happen if the ex-spouse predeceased him, and Plaintiff obtained an amended QDRO that provided that the benefit would revert back to him if the ex-spouse predeceased him. The court granted the motion, finding that under the facts of this case the Plan Administrator’s refusal to recognize the fact that the ex-spouse’s interest terminated on her death and reverted to Plaintiff as required by the amended QDRO was arbitrary and capricious. “It is obvious that where the QDRO is silent, and there is no default rule, and a beneficiary dies prior to her interest vesting, there is nothing to revert to the Fund.” The court found that there was no reason to not apply the amended QDRO even though it was entered after the ex-spouse’s death, explaining that courts have held that ERISA does not prohibit application of posthumous QDROs.
ERISA claims dismissed where plaintiff did not plead status as a plan participant. Pursell v. Spence-Brown, et al., No. 13-1571(FLW), 2015 WL 9216598 (D.N.J. Dec. 17, 2015) (Judge Freda L. Wolfson). Plaintiff alleged that Local 1033 violated the CBA by failing to include all full and part-time non-managerial, non-officer employees under the provision of the 401(k) plan; that the Local Defendants violated their responsibility under ERISA and the CBA by failing to operate the 401(k) plan prudently and for the exclusive benefit of participants; and that he was discriminated and retaliated against by defendants for exercising rights to which he was entitled under the provisions of the employee benefit plan. The court found that to the extent Plaintiff seeks to represent other Local 1033 employees for alleged ERISA violations, he does not have standing to do so. But more importantly, Plaintiff failed to allege that he was a participant of an employee benefit plan and failure to plead the most basic element of his ERISA claims results in dismissal.
Service provider does not qualify as a beneficiary entitled to sue under ERISA Section 502(a)(1)(B). University of Wisconsin Hospitals and Clinics Authority v. Kay Kay Realty Corp. Flexible Benefit Plan, et al., No. 14-CV-882-BBC, 2015 WL 9028080 (W.D. Wis. Dec. 15, 2015) (Judge Barbara B. Crabb). Plaintiff University of Wisconsin Hospitals and Clinics Authority is a public body created for the purpose of operating a number of healthcare facilities. It filed suit against Defendants Kay Kay Realty Corp. Flexible Benefit Plan, Aetna Life Insurance Company, Aetna Health and Life Insurance Company and Aetna Health Insurance Company for allegedly improperly denying it benefits under the terms of the Kay Kay Realty Corp. Flexible Benefit Plan. Plaintiff also asserted that the administrative procedures Defendants employed to decide its administrative claim did not comport with the procedural requirements set forth in 29 U.S.C. § 1133. The court denied Plaintiff’s motion for summary judgment and granted Defendants’ motion on the basis that Plaintiff failed to demonstrate the existence of any genuine issue of material fact with respect to whether it qualifies as a participant, a beneficiary or a fiduciary empowered to file suit under ERISA’s civil enforcement provisions. The court found that Plaintiff did not produce any evidence that it actually received an assignment of the beneficiary’s rights under the Plan. But, even if it had, the Plan prohibits participants from assigning their claims to third-parties, including participants’ doctors and service providers. The court also rejected Plaintiff’s argument that its status as a beneficiary is based on its network provider contract and on the terms of the Plan itself. The court explained that the Seventh Circuit recently held that a provider’s right to direct payment under a plan does not make it a beneficiary entitled to sue under § 502. See Pennsylvania Chiropractic Association v. Independence Hospital Indemnity Plan, Inc., 802 F.3d 926, 929 (7th Cir. 2015). The court did note that Plaintiff may have contract claims to enforce their negotiated network provider agreements with Aetna but the court lacks jurisdiction over these claims.
Motion to transfer venue granted where sole connection to forum is Plaintiff’s counsel’s law office. Hopkins v. Life Insurance Company of North America, No. 315CV00375GNSCHL, 2015 WL 9244489 (W.D. Ky. Dec. 17, 2015) (Judge Greg N. Stivers). Plaintiff brought suit against LINA for denial of long-term disability benefits in the Western District of Kentucky. She resides in North Carolina, LINA is a Pennsylvania company with its principal place of business in Philadelphia, LifePoint Hospitals, Inc. (the employer who sponsored the LTD Plan) is headquartered in Tennessee, and Hopkins’ treating physicians are all in Virginia. LINA filed a motion seeking to transfer this matter to the Middle District of North Carolina, the district in which Hopkins resides. The court found that consideration of the pertinent factors here leads to the common-sense conclusion that Kentucky is not the proper place for this action, where the sole connection here is Plaintiff’s counsel’s law practice. The court granted LINA’s request and transferred the matter.
Court transfers matter based on forum-selection clause contained in pension plan. Keever v. NCR Pension Plan, et al., No. 3:15-CV-196, 2015 WL 9255342 (S.D. Ohio Dec. 17, 2015) (Judge Walter H. Rice). Defendants sought to enforce Paragraph 8.9 of the NCR Pension Plan, which states: Effective on and after February 11, 2011, any claim or action filed in court or any other tribunal in connection with the Plan by or on behalf of a Participant or beneficiary shall only be brought or filed in the United States District Court for the Northern District of Georgia. Plaintiffs challenged that this forum-selection clause is unenforceable because it was not a “bargained for” provision, and is contrary to public policy. The court followed the majority opinion in Smith v. Aegon Companies Pension Plan, 769 F.3d 922 (6th Cir. 2014), petition for cert, filed, 83 U.S.L.W. 3768 (U.S. Mar. 13, 2015) (No. 14-1168, 14A682), and determined that the forum-selection clause is enforceable. Rather than dismiss the action, the court transferred it to Northern District of Georgia.

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