ERISA Watch – Disability Insurer Must Consider Physical and Mental Stress of Occupation

This week’s notable decision is Popovich v. Metro. Life Ins. Co., No. CV1509791ABMRWX, __F.Supp.3d__, 2017 WL 6546920 (C.D. Cal. Dec. 21, 2017) (Judge Andre Birotte Jr.).  On de novo review, the court determined that Plaintiff submitted reliable evidence that he suffers from a significant heart condition and that he is unable to work at a physically and mentally stressful occupation, including his own occupation as an assistant news editor.  The court considered a doctor’s letter outside of the “administrative record” but declined to admit a letter from SSA granting Plaintiff disability benefits.  The court found that MetLife incorrectly denied Plaintiff LTD benefits under the “Usual Occupation” definition and ordered MetLife to pay those benefits.  The court remanded the case back to MetLife to assess whether Plaintiff is disabled under the “Any Occupation” definition of disability.

Below is a summary of this past week’s notable ERISA decisions by subject matter and jurisdiction.

Attorneys’ Fees

Ninth Circuit

Vyas v. Vyas, No. CV1502152RSWLDFMX, 2017 WL 6557437 (C.D. Cal. Dec. 21, 2017) (Judge Ronald S.W. Lew).  Applying Corder v. Howard Johnson & Co. (establishing that before attorneys’ fees can be awarded against a plaintiff in an ERISA action, the plaintiff must at least survive summary judgment on the possibility that it is an enumerated party under Section 1132(g)), the court denied Defendant’s motion for attorneys’ fees.  Plaintiff’s argument that she was a beneficiary of the Lockheed Plan and thus entitled to a share of the assets in the Lockheed Plan did not survive summary judgment because Plaintiff was unable to prove that she was a beneficiary of the Lockheed Plan.

Class Actions

Ninth Circuit

Reyes, et al. v. Bakery and Confectionery Union and Industry International Pension Fund, No. 14-CV-05596-JST, 2017 WL 6623031 (N.D. Cal. Dec. 28, 2017) (Judge Jon S. Tigar).  In this action brought by Fund participants against the Fund and its trustees for failing to comply with ERISA and the PPA in adopting a pension plan amendment, the court granted final approval of the class action settlement and granted in part Plaintiffs’ motion for attorneys, fees, costs, and incentive awards.  The court concluded that class counsel may be awarded fees from the common fund in addition to any award under ERISA’s fee-shifting statute.  The court reduced the lodestar from $1,806,471 to $1,446,786.  The court found neither an upward nor a downward multiplier to be appropriate.  The court based the percentage fee award on the actual value of the common fund:  $10,225,006.20.  The court awarded 25% of this amount in attorney’s fees.  Cross-checking against the lodestar, this yields a multiplier of 1.77, which is within the range of reasonable common fund fee awards.  The court awarded costs of $348,153 and incentive awards of $1,000 to each of the eleven named class representatives.

Disability Benefit Claims

Fourth Circuit

Archer v. SunTrust Bank, et al., No. 3:17-CV-616, 2017 WL 6550390 (E.D. Va. Dec. 22, 2017) (Judge John A. Gibney, Jr.).  “Archer’s alleged injury for denial of long term disability benefits gives rise to a cause of action under ERISA §§ 502(a)(1)(B). She cannot also bring a claim stemming from the same injury under § 502(a)(3). Therefore, Count II of the complaint fails to state a claim upon which relief can be granted. The Court accordingly grants the defendants’ motion to dismiss Count II.”

Life Insurance & AD&D Benefit Claims

Eighth Circuit

Sepulveda-Rodriguez v. Metlife Group, Inc., et al., No. 8:16CV507, 2017 WL 6628116 (D. Neb. Dec. 28, 2017) (Judge Joseph F. Bataillon).  The court determined that MetLife’s denial of Plaintiff’s claim for optional life insurance benefits was an abuse of discretion.  “The Plan requires proof of good health before optional life insurance is effective. The SPD describes a process of answering five questions. The record before the court does not establish what questions Monarrez was asked, nor does it establish that he answered those questions and what his answers to the questions were.”  Even if it were not an abuse of discretion, Plaintiff would still be entitled to summary judgment against MetLife for breach of fiduciary duty.  MetLife and the employer are proper defendants for the equitable claims and the employer breached its fiduciary duty by failing to timely furnish the SPD.  The court also awarded document penalties against the employer for 19 days totaling $2,090.

Plan Status

Third Circuit

Rizzo v. First Reliance Standard Life Insurance Company, et al., No. 17-CV-745 (PGS), 2017 WL 6626315 (D.N.J. Dec. 28, 2017) (Judge Peter G. Sheridan).  The court determined that the Safe Harbor provision does not apply to Barnes & Noble’s life insurance policy.  The Policy terms do not require employees to contribute to the cost of basic life insurance and the Policy encompassed all eligible employees.  The court rejected Plaintiffs’ argument that since she seeks to recover “voluntary additional life insurance coverage,” her claims fall within the safe harbor provision.  Because the company created a comprehensive package of insurance coverage, the Safe Harbor provision does not apply and ERISA preempts Plaintiffs’ state law claims.

Pleading Issues & Procedure

Fifth Circuit

Ball v. Life Insurance Company of North America, No. 3:17-CV-2366-L, 2017 WL 6621539 (N.D. Tex. Dec. 28, 2017) (Magistrate Judge David L. Horan).  In this dispute over long term disability benefits, the court ordered LINA to file an amended answer to replead its responses to certain allegations consistent with this order and without basing its responses on any assertion that a document “speaks for itself.”  The court also ordered LINA to file an amended answer to replead two affirmative defenses, including that Plaintiff failed to satisfy all the conditions precedent and that Plaintiff failed to comply with the terms of the policy.

Provider Claims

Fifth Circuit

Mem’l Hermann Health Sys. v. Pennwell Corp. Med. & Vision Plan, No. CV H-17-2364, 2017 WL 6561165 (S.D. Tex. Dec. 22, 2017) (Judge Sim Lake).  The court granted Defendants’ motion to dismiss, holding that anti–assignment provisions are enforceable, the anti-assignment provision is not ambiguous, and Plaintiff has not alleged facts capable of showing that Defendants waived or are estopped from enforcing the anti–assignment provision.  As to Plaintiff’s claim of derivative standing, the court found that Plaintiff has not alleged independent standing.

Statute of Limitations

Third Circuit

Rizzo v. First Reliance Standard Life Insurance Company, et al., No. 17-CV-745 (PGS), 2017 WL 6626315 (D.N.J. Dec. 28, 2017) (Judge Peter G. Sheridan).  The court determined that Plaintiffs’ claim for survivorship benefits under the life insurance policy is not time barred.   Under the terms of the policy, “no legal action may be brought against us to recover on this Policy … after three (3) years from the time written proof of loss is received.”  The court disagreed that the clock began to run when the October 9th letter, which denied Plaintiffs’ application for waiver of life insurance premium, was sent.  Since Defendant continued to pay total disability benefits until the date of Decedent’s death, it is probable that Plaintiffs believed the waiver of premium was authorized.  The clock began to run on March 6, 2014, the date of the first letter denying life insurance benefits.  The court concluded that the suit was timely filed.

Sixth Circuit

The Grand Traverse Band of Ottawa & Chippewa Indians, & Its Employee Welfare Plan v. Blue Cross & Blue Shield of Michigan, No. 14-CV-11349, 2017 WL 6594220 (E.D. Mich. Dec. 26, 2017) (Judge Judith E. Levy).  The court denied Plaintiffs’ motion for reconsideration of the dismissal of the breach of fiduciary duty claim as time-barred.  Plaintiffs claimed that BCBSM breached fiduciary duties with respect to the payment of certain claims at Medicare-Like Rates (“MLR”).  In March 2009, Plaintiffs entered into an agreement, outside of their ERISA plan, which explicitly stated that they would not receive MLR.  The court found this sufficient to constitute actual knowledge of a breach of fiduciary duty.  The court also denied Plaintiffs’ motion for leave to file a second amended complaint since they plead no set of facts that could plausibly lead to the conclusion that the six-year statute of limitations under ERISA for fraud or concealment applies.