Happy Monday! There were a few notable district court decisions this past week. In a long-standing case, the Western District of New York found the equitable remedy of contract reformation appropriate to remedy equitable fraud caused by an employer’s inadequate notice of a reduction of pension benefits. The Southern District of Ohio upheld the application of the Affordable Care Act’s Transitional Reinsurance Program to group health plans operated by state or local governments. The Northern District of California found that a same-sex spouse, who was denied survivor benefits, adequately alleged that FedEx and other defendants breached their fiduciary duty for interpreting the pension plan in a manner that violates Title I of ERISA. The Northern District of Indiana found that a disability insurer abused its discretion in denying benefits, specifically criticizing the insurer’s use of medical reviewers whose “bread has been buttered” by the insurer before. Speaking of, time for breakfast! Read more about these and other decisions in this week’s ERISA Watch.
Your reliable source for summaries of recent ERISA decisions
Below is Roberts Disability Law summary of this past week’s notable ERISA decisions.
Equitable remedy of contract reformation is appropriate to redress violation of ERISA’s notice requirements. Frommert v. Becker, No. 00-CR-6311L, __F.Supp.3d___, 2016 WL 64678 (W.D.N.Y. Jan. 5, 2016) (Judge David G. Larimer). On remand from the Second Circuit Court of Appeals, the district court was tasked with determining the form of remedy Plaintiffs are entitled to as a result of Xerox’s failure to give adequate notice of the circumstances that would result in an offset or reduction of pension benefits to former employees who took a lump-sum payment of a prior distribution before starting a second term of employment at Xerox. It is now undisputed that Defendants’ application of the “phantom account” violated Plaintiffs’ rights under ERISA, and that Plaintiffs are entitled to relief for that violation. The court determined that Defendants’ notice violations justify the imposition of an equitable remedy, and as such, the court need not analyze and consider Xerox’s latest interpretation of the Plan with respect to how benefits should be calculated. The court found that a “new hire” remedy is an appropriate equitable remedy: Plaintiffs will receive whatever benefits they are due for their second period of employment, the same as if they were new hires. The court found that this remedy will fully compensate Plaintiffs for all their years of service. Plaintiffs’ prior lump-sum distribution will have no effect on the employee’s subsequent benefits. The court applied a remedy of contract reformation. Under principles of long standing, a contract may be reformed due to the mutual mistake of both parties, or where one party is mistaken and the other commits fraud or engages in inequitable conduct. The court found that equitable fraud does not require a showing of intent to deceive or defraud. Inequitable conduct – deception or even mere awareness of the other party’s mistake combined with superior knowledge of the subject of that mistake – is enough to support reformation when combined with the plaintiff’s mistake. The court found that Xerox’s failure to disclose the operation of the phantom account, combined with its intransigence in defending the use of the phantom account, produced an inequitable result, the kind of harm that the concept of equitable fraud was designed to remedy. In fashioning this remedy, the court found irrelevant how the individual plaintiffs actually disposed of their initial lump-sum payments (i.e., whether they had spent it all or made money from investment). The court rejected Defendants’ argument that Plaintiffs are not entitled to this relief because this remedial theory was not sought in the complaint.
Affordable Care Act’s Transitional Reinsurance Program applies to group health plans operated by state or local governments and is constitutional. State of Ohio v. United States, No. 2:15-CV-321, __F.Supp.3d___, 2016 WL 51226 (S.D. Ohio Jan. 5, 2016) (Judge Algenon L. Marbley). The Affordable Care Act of 2010 (“the Act”) contains a provision known as the Transitional Reinsurance Program, a feature designed to stabilize prices in the individual insurance market during the first three years of the Act’s guaranteed-issue and community-rating reforms. The State of Ohio challenged the Act’s Transitional Reinsurance Program, arguing that the health plans it provides to its employees are not required to make reinsurance contributions because the plans are not “group health plans” within the meaning of the ACA, and alternatively, requiring its health plans to make these contributions violates the Tenth Amendment and Intergovernmental Tax Immunity Doctrine. The court granted the government’s motion to dismiss and denied the State of Ohio’s motion for summary judgment. First, the court determined that it may entertain the state’s statutory claims because binding precedent establishes jurisdiction over the State’s tax-refund claim and the court may hear the State’s Administrative Procedures Act claim. It found that the text, structure, and purpose of the Act confirms that Congress intended for all group health plans, including those operated by state or local governments, to pay into the Transitional Reinsurance Program. Specifically, the court found that “Non-Federal Governmental Plans” offering qualifying medical care constitute a subset of “Group Health Plans” under the Public Health Service Act, which provides the operative definition for this dispute. Any other interpretation would render many of the Act’s statutory revisions meaningless, yield a null set with respect to the PHSA’s enforcement provisions, and would exempt state and local governmental plans from most of the significant reforms contained in the Act. Further, “Governmental Plans” constitute a type of “Employee Welfare Benefit Plan” under ERISA, the definitions of which the PHSA incorporates. Any other interpretation would render ERISA’s governmental plan exclusion superfluous. Moreover, Congress and the Department of Health and Human Services did not violate the Constitution when they subjected health plans offered by state and local government employers to the same requirements as those offered by private-sector employers. The court found that it is constitutional under both the Tenth Amendment and the Intergovernmental Tax Immunity Doctrine because the program regulates state and local governments in their capacity as employers, does not commandeer the legislative or executive apparatuses of state or local governments, and does not discriminate against state or local governments in the contributions imposed.
Motion for judgment on the pleadings denied as to a breach of fiduciary duty claim brought by same-sex surviving spouse against FedEx for interpreting pension plan in a manner that violates Title I of ERISA. Schuett v. Fedex Corp., No. 15-CV-0189-PJH, __F.Supp.3d___, 2015 WL 9628588 (N.D. Cal. Jan. 4, 2016) (Judge Phyllis J. Hamilton). This case involves a denial of a qualified joint and survivor annuity to a surviving same-sex spouse. The Plan provides for payment of the benefit to a Spouse (defined in 1 U.S.C.A. § 7) as the time of the plan participant’s death. Here, Plaintiff and her now deceased spouse/plan participant were married in a civil ceremony on June 19, 2013 before Plaintiff’s wife died on June 20, 2013. On June 26, 2013, the U.S. Supreme Court declared § 3 of DOMA unconstitutional. On June 28, 2013, the Ninth Circuit lifted its stay directing California officials to stop enforcing Prop 8. On September 18, 2013, the Superior Court of California issued an Order declaring that Plaintiff and her wife were married on June 19, 2013. FedEx denied benefits to Plaintiff on the basis that she was not a spouse at the time of her wife’s death.
After unsuccessfully exhausting administrative remedies, Plaintiff filed suit alleging three causes of action in the alternative- (1) a claim for benefits under ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B) (against all defendants); (2) a claim of breach of fiduciary duty under ERISA § 502(a)(3), 29 U.S.C. § 1132(a)(3) (against FedEx Corporation and FedEx RAC), for failure to administer the Plan in accordance with applicable law; and (3) a claim of breach of fiduciary duty under ERISA § 502(a)(3), 29 U.S.C. § 1132(a)(3) (against FedEx Corporation), for failure to inform and/or for providing misleading communications. The third cause of action was based on the claim that FedEx did not inform the plan participant that Plaintiff would have been eligible for a reduced benefit if she retired before she died so the plan participant did not choose to retire although she would have.
Defendants filed a motion for judgment on the pleadings which the court granted in part and denied in part. With respect to the ERISA § 502(a)(1)(B) claim, the court found that Plaintiff and her spouse were married on June 19, 2013, but because at the time of their marriage DOMA was in effect and the Plan did not recognize same-sex marriages, FedEx did not abuse its discretion in interpreting the Plan as not requiring payment of a spousal survivor annuity to Plaintiff. The court denied the motion as to Count II because Plaintiff adequately alleged that FedEx violated Title I of ERISA by acting contrary to applicable federal law and failing to provide Plaintiff with a benefit mandated by ERISA, and that she is entitled to pursue equitable relief to remedy that violation. Title I of ERISA provides that each covered pension plan shall provide that “in the case of a vested participant who dies before the annuity starting date and who has a surviving spouse, a qualified preretirement survivor annuity shall be provided to the surviving spouse of such participant.” 29 U.S.C. § 1055(a)(2). The court saw no basis at this stage of the case and under the facts alleged in the complaint for denying retroactive application of Windsor. Although the court discussed Defendants’ argument that Plaintiff could not resort to § 502(a)(3) because she had an adequate remedy under § 502(a)(1)(B), the court did directly rule or address this issue. It did note Plaintiff’s contention that she is not foreclosed from seeking relief under both provisions because the first cause of action seeks Plan benefits whereas the second cause of action seeks a survivor benefit as mandated by ERISA. Plaintiff further contented that if she succeeds on both claims, she will recover only one survivor benefit but that at the pleading stage she should be permitted to pursue both claims. The court granted Defendants’ motion as to Count III because Plaintiff was neither a participant nor beneficiary and lacks standing to bring an action for breach of fiduciary duty. Because Plaintiff’s spouse did not choose to retire before her death, Plaintiff could not be a beneficiary under the provision of the Plan that provides benefits to beneficiaries after the retirement of the participant.
Select Slip Copy & Not Reported Decisions
Disability Benefit Claims
Aetna abused its discretion in denying claims; matter remanded for full and fair review. Maiden v. Aetna Life Insurance Company, et al., No. 3:14-CV-901, 2016 WL 81489 (N.D. Ind. Jan. 6, 2016) (Judge Philip P. Simon). In this matter seeking review of a denial of LTD benefits and waiver of life insurance premium benefits, the court denied Defendants’ motion to dismiss the disability plan as a defendant. The court found that Aetna’s notices to Plaintiff did not substantially comply with ERISA’s disclosure requirements and the shortcomings in Aetna’s pre-appeal letters could have left-and apparently did leave-significant gaps in Plaintiff’s understanding of what information was needed to perfect his claim. The court found that Aetna’s failure to provide Plaintiff with adequate information about why his claim had been denied before Aetna’s internal review prevented Plaintiff from receiving a full and fair opportunity for review, and for this reason alone Plaintiff is entitled to summary judgment. Further, the court found that Aetna should have reviewed the compound effect of Plaintiff’s physical impairments and his psychiatric issues, and its failure to do so was an arbitrary and capricious exercise of Aetna’s discretion. The court found that Aetna inexplicably disregarded the opinions of treating physicians and ignored evidence supporting disability while cherry-picking evidence to support a denial. Aetna used consultants with an incentive to affirm. “I put quotations marks around the word “independent” because one might reasonably wonder just how independent the reviewers-Dr. Malcolm McPhee and Dr. Leonard Schnur-really are. Their bread has been buttered by Aetna before; each of them has been hired by Aetna multiple times to conduct these kinds of disability reviews.” The court found that it’s clear that Aetna abused its discretion and Maiden must be given another opportunity to prove his claim.
Prevailing claimant entitled to prejudgment interest at the rate set out in 28 U.S.C. § 1961, not at the Oregon statutory rate. Culp v. Metropolitan Life Insurance Company, No. 3:14-CV-01133-PK, 2016 WL 96150 (D. Or. Jan. 8, 2016) (Judge Anna J. Brown). On Defendants’ objections to the Magistrate Judge’s recommendation that Plaintiff is entitled to prejudgment interest at the Oregon statutory rate, the court declined to adopt the Magistrate Judge’s recommendation and awarded prejudgment interest at the rate set out in 28 U.S.C. § 1961. The court explained that Plaintiff does not point to any evidence in the record to establish that he suffered the loss of his ability to invest money in funds at a rate of return higher than that earned on T-Bills or that he had to borrow money at a higher rate to compensate for lost benefits. Plaintiff relied on a case from the Western District of Tennessee (Warden v. MetLife) to support his claim that the rate of prejudgment interest should be determined under state law unless MetLife can demonstrate that it overcompensates Plaintiff. The court found that this case relies on a Sixth Circuit case that does not support an award of prejudgment interest at the state’s rate, rather, it noted that a district court may look to state law for guidance. The court pointed to other decisions from this court declining to award prejudgment interest in ERISA benefits cases at the Oregon statutory rate or at rates different from the one set out in § 1961.
Exhaustion of Administrative Remedies
Complaint dismissed for failure to exhaust elimination of disability benefits due to offsets for other income. Thomas v. Metropolitan Life Insurance Company, et al., No. 15-1733, 2016 WL 80634 (E.D. La. Jan. 7, 2016). After filing her claim for disability benefits, Plaintiff received a letter informing her that her monthly benefit under the LTD Plan was being reduced as a result of her SSDI award. She later received a letter which informed her that her benefits were being eliminated entirely as a result of her receipt of retirement benefits. Plaintiff did not contest ExxonMobil’s assertion that she failed to file an administrative appeal after receiving these communications. The court granted ExxonMobil’s Rule 12(b)(6) motion because Plaintiff could not prove that (1) the controlling terms of her plan did not impose an administrative appeal requirement or (2) the administrative appeal requirement fails to comply with applicable regulations.
Medical Benefit Claims
Denial of coverage for Christian Science care not an abuse of discretion. Summersgill v. E.I. du Pont de Nemours and Company, et. al., No. 13-CV-10279, 2016 WL 94247 (D. Mass. Jan. 6, 2016) (Judge Denise J. Casper). The court granted Defendants’ motion for summary judgment on Plaintiff’s claim that Defendants improperly denied his late mother reimbursement for certain care she received at a Christian Science facility. DuPont ultimately denied claims for Mrs. Summersgill’s care at Christian Science care at Chestnut Hill Benevolent Association on the basis that it was custodial, not medically necessary or because insufficient clinical information was provided. The court found that it was not an abuse of the discretion for DuPont to rely on the opinion of a medical professional who used Milliman Care Guidelines in coming to his or her conclusion as there is no language in the Plan suggesting that DuPont must apply Christian Science care guidelines in making a coverage determination.
Retiree health benefits are not vested. Barton v. Constellium Rolled Products-Ravenswood, LLC, et al., No. 2:13-CV-03127, 2016 WL 51262 (S.D.W. Va. Jan. 4, 2016) (Judge Joseph R. Goodwin). On the parties’ motions for summary judgment, the court was tasked with resolving a single issue: whether the retirees had a vested right to retiree health benefits. The court concluded that retiree health benefits were not vested, finding that Judge Copenhaver’s Dewhurst opinion compels the outcome of this case. See Dewhurst v. Century Aluminum Co., No. 2:09-cv-01546, 2015 WL 5304616 (S.D. W. Va. Sept. 9, 2015). Benefits are not vested based on clear and unambiguous language of the collective bargaining agreement at issue. The relevant CBAs include clear and unambiguous durational clauses, which provide that retiree health benefits last for the term of the operative CBA. The court found that Plaintiffs’ extrinsic evidence, including letters concerning retiree health benefits, cannot be considered in the absence of an ambiguity.
Plaintiffs are entitled to reimbursement for out-of-pocket expenses related to ABA therapy; equitable relief claim may also proceed. A.F., et al. v. Providence Health Plan, No. 3:13-CV-00776-SI, 2016 WL 81796 (D. Or. Jan. 7, 2016) (Judge Michael H. Simon). The court previously ruled on cross-motions for summary judgment that Providence’s Developmental Disability Exclusion violates the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and therefore is prohibited under ERISA. On the parties’ respective motions on Plaintiffs’ second amended class action complaint, the court granted in part and denied in part Plaintiff’s motion for summary judgment on their recovery of benefits claim under 29 U.S.C. § 1132(a)(1)(B). The court found that the individual plaintiffs were due reimbursement for out-of-pocket expenses for ABA therapy but denied a portion of one plaintiff’s claim because there was no evidence that Providence ever received the claim form. The court denied Providence’s motion on Plaintiff’s claim for equitable relief under 29 U.S.C. § 1132(a)(3) sufficient to redress Providence’s violations of its fiduciary duty, on behalf of all named Plaintiffs. The court found that Plaintiffs have sufficiently pled that reimbursement under Section 1132(a)(1)(B) does not provide them with “adequate relief” to remedy Providence’s breach of fiduciary duty. Although Plaintiffs may not simply “repackage” their Section 1132(a)(1)(B) claim and thus obtain duplicative relief, the court cannot conclude at the motion to dismiss stage that the two claims are indeed duplicative. The court rejected Defendant’s argument that Plaintiffs are seeking compensatory damages precluded by the Ninth Circuit’s ruling in Bast v. Prudential Insurance Co. of America, 150 F.3d 1003 (9th Cir. 1998).
Pleading Issues & Procedure
Counterclaims may not be dismissed for lack of subject matter jurisdiction. Wilhelm v. Beasley, No. 15-CV-4029 (LAK), 2016 WL 94254 (S.D.N.Y. Jan. 7, 2016) (Judge Lewis A. Kaplan). This matter is one of several actions relating to the decision of the National Retirement Fund to expel the Caesars Employers from the Legacy Plan of the Fund. The Defendants are the Fund itself and the trustees who voted for the expulsion. The court sustained Defendants objections to the R&R’s recommendation that counterclaim Counts 1, 2 and 4 be dismissed for lack of subject matter jurisdiction. The court did not find that litigation of the remaining part of the counterclaim, which may well be susceptible to disposition either by deciding the merits of the Rule 12(b)(6) motion already made or on summary judgment and seems to raise relatively finite issues, would be terribly burdensome to the court or the parties. The court explained that the vitality of the prudential element of the ripeness analysis recently has been questioned by the Supreme Court, which has observed that it is in some tension with the principle that a federal court’s obligation to hear and decide cases within its jurisdiction is virtually unflagging. The court remanded the matter to the magistrate judge for further proceedings with respect to the motion to dismiss Counts 1, 2 and 4 on the ground that they fail to state a claim upon which relief may be granted.
Claim related to cancellation of health insurance benefits is inadequately pled under Rule 12(b)(6). Jassie v. Mariner, No. CV DKC 15-1682, 2016 WL 67257 (D. Md. Jan. 6, 2016) (Judge Deborah K. Chasanow). Defendant moved to dismiss Plaintiff’s claim for wrongful cancellation of health insurance – interpreted as a breach of contract claim – due to ERISA preemption and Defendant is not a proper ERISA defendant. Here, Plaintiff alleges that he was entitled to health insurance benefits that he did not receive but the court found that the amended complaint is vague and the court cannot determine whether Plaintiff’s wrongful cancellation claim is covered by ERISA. If Plaintiff is asserting a claim that the employer breached the terms of his employment contract, part of which entailed an obligation to provide benefits during the course of employment, such a claim would not be preempted by ERISA. The court found unclear from the amended complaint whether Plaintiff’s insurance coverage was cancelled prematurely or at the time Plaintiff’s employment was terminated since Plaintiff does not provide precise dates for either the cancellation of his insurance coverage or the termination of his employment. Any converted ERISA claim cannot be sustained because Plaintiff did not bring suit against the plan, the plan administrator, or a plan fiduciary. In addition, the amended complaint does not contain plausible allegations that Defendant breached contractual duties owed to Plaintiff as Plaintiff’s employment contract appears to be with his employer, rather than Defendant, a regional human resources manager. For these reasons, the court found that the amended complaint cannot withstand Rule 12(b)(6) scrutiny and dismissed Plaintiff’s claim.
Plaintiff released and could no longer accrue ERISA claims in connection with deferred equity compensation upon execution of release agreement. Manuel vs. Aventine Renewable Energy Holdings, Inc., et al., No. 8:15CV188, 2016 WL 54201 (D. Neb. Jan. 4, 2016) (Judge Laurie Smith Camp). Plaintiff brought suit alleging that Aventine failed to comply with the terms of the Equity Plan, through which he received awards of deferred equity compensation including stock options. Plaintiff signed a release of claims when his employment ended and had agreed that all outstanding equity awards granted to him were fully vested and exercisable. Defendants moved to dismiss Plaintiff’s ERISA claim, arguing that the Equity Plan and Restricted Stock Unit Agreement did not create an ERISA plan, but regardless, he waived any claims and limited his remedies to those for breach of contract. The court did not decide whether portions of the equity awards constituted, or were distributed pursuant to, an ERISA-governed benefits plan because Plaintiff waived all ERISA claims by agreeing to the Release, and he cannot accrue new claims subsequent to its signing. Plaintiff argued that his release of his ERISA claims only applied to claims that had accrued up to or before the signing the Release, and that any claims that arose subsequent to the signing could not have been knowingly and voluntarily released. The court found that he is only half-correct: after Plaintiff released his rights, he could no longer accrue claims under ERISA. The court explained that an alternate conclusion would render Plaintiff’s promise to bring all subsequent claims as a breach of the Release devoid of meaning. Accordingly, the court dismissed the ERISA claims.
Severance Benefit Claims
Motion to dismiss claim for severance benefits denied where Defendants failed to establish that the claimant was “terminated” as defined in the Plan. Ditchey v. Mechanics Bank, No. 15-CV-04103-JSC, 2016 WL 80560 (N.D. Cal. Jan. 7, 2016) (Magistrate Judge Jacqueline Scott Corley). Plaintiff submitted a claim to Mechanics Bank seeking severance benefits under the Mechanics Bank Change in Control Plan because there had been a material diminution in the scope of her responsibilities, duties or authority following the “Change in Control” which resulted in her Involuntary Termination. Defendants did not respond within the 30-day response period so Plaintiff filed suit alleging a Section 502(a)(1)(B) claim. Defendants moved to dismiss on the basis that Plaintiff did not satisfy a condition precedent to receiving benefits – that she sign a release agreement within 30 days of her Termination. Defendants also argued that Plaintiff lacked standing. The court denied Defendants’ motion because Defendants did not establish as a matter of law that Plaintiff incurred a “Termination” within the meaning of the Plan. The court rejected Defendants’ related argument that Plaintiff lacks standing to bring suit because she is not an eligible Plan participant as she has not submitted the release. For standing purposes, all Plaintiff needs to show is that she has suffered an injury in fact, that the injury is traceable to the challenged action of the defendant, and that the injury can be redressed by a favorable decision.
Statutory Damages & Notice Violations
Section 1133(2) does not provide for a private cause of action and document penalties are only available against the designated plan administrator. Swanson v. Aetna Life Insurance Company, No. 15-CV-0785-WYD-CBS, 2016 WL 54118 (D. Colo. Jan. 5, 2016) (Judge Wiley Y. Daniel). Plaintiff brought suit for the denial of Accidental Death and Personal Loss benefits under an ERISA plan sponsored by Bank of America. Aetna, the claims administrator, denied the claim on the basis that Plaintiff’s -+-spouse’s death was not a covered loss under the terms of the plan. Plaintiff brought two claims for relief, the first for benefits under 29 U.S.C. § 1133(2) and the second for penalties under 29 U.S.C. § 1132(c)(1). The court found that Section 1133(2) does not provide for a private cause of action for the recovery of denied benefits, rather it provides for a full and fair review of a denial decision. Based on case law, failure to comply with this procedural requirement does not create a private remedy. Here, Plaintiff did not allege any failure on the part of the plan, but instead asserted that Aetna and Bank of America failed under the requirements of this subsection of the statute. But, the Tenth Circuit has established that there is no private right of action under Section 1133 for claims against employers or plan administrators. The court also found that Plaintiff’s § 1132(c)(1)(B) claim could only be brought against the plan administrator, Bank of America, and not Aetna. Plaintiff only requested documents from Aetna. Plaintiff had dismissed Bank of America from the case and the court rejected Plaintiff’s contention that she inadvertently failed to correct the stipulation to dismiss Aetna instead of Bank of America. The court granted Defendants’ motion to dismiss on both claims.
* Please note that these are only case summaries of decisions as they are reported and do not constitute legal advice. These summaries are not updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The cases reported above were handled by other law firms but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law may be able to advise you so please contact us. Case summaries authored by Michelle L. Roberts, Partner, Roberts Disability Law, 1050 Marina Village Pkwy., Ste. 105, Alameda, CA 94501; Tel: 510-230-2090.
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