Justia U.S. 6th Circuit Court of Appeals Opinion Summaries

Articles Posted in ERISA
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The Labor Management Relations Act forbids employers from directly giving money to unions, 29 U.S.C. 186(a); an exception allows an employer and a union to operate a trust fund for the benefit of employees. Section 186(c)(5)(B) requires the trust agreement to provide that an arbitrator will resolve any “deadlock on the administration of such fund.” Several construction companies and one union established a trust fund to subsidize employee vacations. Six trustees oversaw the fund, which is a tax-exempt entity under ERISA 26 U.S.C. 501(c)(9). A disagreement arose over whether the trust needed to amend a tax return. Three trustees, those selected by the companies, filed suit, seeking authority to amend the tax return. The three union-appointed trustees intervened, arguing that the dispute belongs in arbitration.The court agreed and dismissed the complaint. The Sixth Circuit affirmed. While ERISA plan participants or beneficiaries may sue for a breach of statutory fiduciary duty in federal court without exhausting internal remedial procedures, this complaint did not allege a breach of fiduciary duties but rather alleges that the employer trustees’ own fiduciary duties compelled them to file the action to maintain the trust’s compliance with tax laws. These claims were “not directly adversarial to the [union trustees] or to the Fund.” View "Baker v. Iron Workers Local 25" on Justia Law

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In 2002, Nolan’s employer, DTE, created a cash balance pension plan and invited its existing employees to transfer from their traditional defined benefit plan to the new plan. Nolan accepted. When she retired in 2017, DTE told Nolan that her monthly pension benefit would be what she had accrued as of 2002 under the old plan, despite her participation in the new cash balance plan. Nolan brought a class action under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001(a)–(b), alleging that DTE made misleading promises and failed to explain the new plan’s risks. The district court dismissed. The Sixth Circuit affirmed in part, finding Nolan’s procedural claim untimely. Even accepting Nolan’s allegations as true, Nolan failed to state a claim under ERISA section 204(h); DTE satisfied the requirement to make a good faith effort to comply even though the notice provided to employees was ultimately inadequate under ERISA section 102. Reversing in part, the court found that Nolan stated a plausible claim that DTE’s notice was defective under section 102 because it failed to describe the plan in a manner understandable to the average participant that employees transferring to the new plan would not actually receive any new benefits if the benefit accrued under the new plan did not catch up to their frozen traditional plan benefit or the effect that interest rates could have on depreciating the already-earned benefits during conversion. View "Nolan v. Detroit Edison Co." on Justia Law

Posted in: ERISA
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Davis, insured under a Hartford long-term disability policy, began missing work due to chronic back pain, neuropathy, and fatigue caused by multiple myeloma. Relying on the opinion of Davis’s oncologist, Dr. Reddy, Hartford approved Davis’s claim for short-term disability benefits through April 17, 2012. In June, Hartford approved Davis for long-term disability benefits, retroactive to April, for 24 months. Davis could continue to receive benefits beyond that time if he was unable to perform one or more of the essential duties of “Any Occupation” for which he was qualified by education, training, or experience and that has comparable “earnings potential.” Reddy's subsequent reports were inconsistent. An investigator found “discrepancies" based on surveillance. Davis’s primary care physician and neurologist both concluded that Davis could work full-time under described conditions. Reddy disagreed, but would not answer follow-up questions. An orthopedic surgeon conducted an independent review and performed an examination, and reported that Davis was physically capable of “light duty or sedentary work” within certain restrictions. Other doctors agreed. Hartford notified Davis that he would be ineligible for benefits after April 17, 2014.Davis filed suit under the Employee Retirement Income Security Act, 29 U.S.C. 1132(a). The Sixth Circuit affirmed summary judgment in favor of Hartford. Hartford reasonably concluded that Davis could work full-time, under certain limitations; the decision was not arbitrary. View "Davis v. Hartford Life & Accident Insurance Co." on Justia Law

Posted in: ERISA, Insurance Law
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Donna’s former husband, Carl, retired from Ford in 1998 and participated in Ford’s retirement plan. “In the event of an error” in calculating a pension, the plan requires a beneficiary to return the overpayment “without limitation.” A committee runs the plan, with “discretionary authority" to reduce the repayment. Carl and Donna divorced in 2009. Donna received half of the marital portion of Carl’s pension. Donna agreed to postpone drawing the pension. In 2013, Ford offered a lump sum payment in place of future monthly benefits and a $351,690 retroactive payment for the postponed monthly benefits. After paying taxes, Donna invested some of the money and gave some to her children. Ford audited Donna’s benefits. It discovered that the retroactive pension payment mistakenly included benefits from 1998, when Carl retired, instead of 2009. The payment should have been $108,500. Ford requested repayment; the committee invited Donna to apply for a hardship reduction. The application required disclosure of her finances, including her other substantial retirement funds and an inheritance. Donna did not apply; she sued.The Sixth Circuit affirmed summary judgment for Ford. The committee’s actions were neither wrong nor arbitrary. Donna did not establish that Ford’s inclusion of an incorrect retroactive-payment amount constituted constructive fraud. She knew that the retroactive payment was too high when she got it, the plan put her on notice that Ford could demand repayment, and she has the capacity to return the money. View "Zirbel v. Ford Motor Co." on Justia Law

Posted in: Contracts, ERISA
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Beginning in‌ ‌‌2017,‌ ‌DaVita‌ ‌provided‌ ‌dialysis‌ ‌treatment‌ ‌to‌ ‌Patient‌ ‌A,‌ ‌who was ‌diagnosed‌ ‌ with‌ ‌end-stage‌ ‌renal‌ ‌disease‌ ‌(ESRD).‌ ‌‌Patient‌ ‌A‌ assigned his‌ ‌insurance‌ ‌rights‌ ‌to‌ ‌DaVita.‌ ‌Through‌ August‌ ‌2018,‌ ‌the‌ ‌costs‌ ‌of‌ ‌Patient‌ ‌A’s‌ ‌dialysis‌ ‌were‌ ‌reimbursed‌ ‌by‌ ‌the‌ ‌Employee‌ ‌Health‌ ‌Benefit‌ ‌Plan,‌ ‌governed‌ ‌by‌ ‌the‌ ‌Employee‌ ‌Retirement‌ ‌Income‌ ‌Security‌ ‌Act‌ ‌(ERISA), ‌at‌ ‌its‌ ‌bottom‌ ‌tier,‌ ‌which‌ ‌applied‌ ‌to‌ ‌providers‌ ‌who‌ ‌are‌ ‌“out-of-network.”‌ ‌All‌ ‌dialysis‌ ‌providers‌ were‌ ‌out-of-network.‌ ‌While‌ ‌most‌ ‌out-of-network‌ ‌providers‌ ‌are‌ ‌reimbursed‌ ‌in‌ ‌the‌ ‌bottom‌ ‌tier‌ ‌based‌ ‌on‌ ‌a‌ ‌“reasonable‌ ‌and‌ ‌customary”‌ ‌fee‌ ‌as‌ ‌understood‌ ‌in‌ ‌the‌ ‌healthcare‌ ‌industry,‌ ‌dialysis‌ ‌providers‌ ‌are‌ ‌subject‌ ‌to‌ ‌an‌ ‌“alternative‌ ‌basis‌ ‌for‌ ‌payment”;‌‌‌ ‌the‌ ‌Plan‌ ‌reimburses‌ ‌at‌ 87.5%‌ ‌of‌ ‌the‌ ‌Medicare‌ ‌rate.‌ ‌Patient‌ ‌A‌ ‌was exposed‌ ‌to‌ ‌higher‌ ‌copayments,‌ ‌coinsurance‌ ‌amounts,‌ ‌and‌ ‌deductibles and ‌was‌ ‌allegedly‌ ‌at‌ ‌risk‌ ‌of‌ ‌liability‌ ‌for‌ ‌the‌ ‌balance‌ ‌of‌ ‌what‌ ‌was‌ ‌not‌ ‌reimbursed‌ .‌ ‌The‌ ‌Plan‌ ‌identified‌ ‌dialysis‌ ‌as‌ ‌subject‌ ‌to‌ ‌heightened‌ ‌scrutiny,‌ ‌ ‌which‌ ‌allegedly‌ ‌incentivizes‌ ‌dialysis‌ ‌patients‌ ‌to‌ ‌switch‌ ‌to‌ ‌Medicare. Patient‌ ‌A‌ ‌switched‌ ‌to‌ ‌Medicare.‌ ‌DaVita‌ ‌and‌ ‌Patient‌ ‌A‌ ‌sued,‌ ‌alleging‌ ‌that‌ ‌the‌ ‌Plan‌ ‌treats‌ ‌dialysis‌ ‌providers‌ ‌differently‌ ‌from‌ ‌other‌ ‌medical‌ ‌providers‌ ‌in‌ ‌violation‌ ‌of‌ ‌the‌ ‌Medicare‌ ‌Secondary‌ ‌Payer‌ ‌Act‌ ‌(MSPA)‌ ‌and‌ ‌ERISA.‌ ‌ ‌ ‌ The‌ ‌Sixth‌ ‌Circuit‌ ‌reversed,‌ ‌in‌ ‌part,‌ ‌the‌ ‌dismissal‌ ‌of‌ ‌the‌ ‌claims.‌ ‌A‌ ‌conditional‌ ‌payment‌ ‌by‌ ‌Medicare‌ ‌is‌ ‌required‌ ‌as‌ ‌a‌ ‌precondition‌ ‌to‌ ‌suing‌ ‌under‌ ‌the‌ ‌MSPA’s‌ ‌private‌ ‌cause‌ ‌of‌ ‌action;‌ ‌the‌ ‌complaint‌ ‌sufficiently alleges ‌such‌ ‌a‌ ‌payment‌.‌ ‌DaVita‌ ‌plausibly‌ ‌alleged‌ ‌that‌ ‌the‌ ‌Plan‌ ‌violates‌ ‌the‌ ‌nondifferentiation‌ ‌provision‌ ‌of‌ ‌the‌ ‌MSPA,‌ ‌resulting‌ ‌in‌‌ ‌denials‌ ‌of‌ ‌benefits‌ ‌and‌ ‌unlawful‌ ‌discrimination‌ ‌under‌ ‌ERISA.‌ ‌ View "DaVita, Inc. v. Marietta Memorial Hospital Employee Health Benefit Plan" on Justia Law

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Title IV of the Employee Retirement Income Security Act of 1974 (ERISA) creates an insurance program to protect employees’ pension benefits. The Pension Benefit Guaranty Corporation (PBGC)—a wholly-owned corporation of the U.S. government—is charged with administering the pension-insurance program. PBGC terminated the “Salaried Plan,” a defined-benefit plan sponsored by Delphi by an agreement between PBGC and Delphi pursuant to 29 U.S.C. 1342(c). Delphi had filed a voluntary Chapter 11 bankruptcy petition and had stopped making contributions to the plan. The district court rejected challenges by retirees affected by the termination.The Sixth Circuit affirmed. Subsection 1342(c) permits termination of distressed pension plans by agreement between PBGC and the plan administrator without court adjudication. Rejecting a due process argument, the court stated that the retirees have not demonstrated that they have a property interest in the full amount of their vested, but unfunded, pension benefits. PBGC’s decision to terminate the Salaried Plan was not arbitrary and capricious. View "Black v. Pension Benefit Guaranty Corp." on Justia Law

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Wallace participated in Oakwood’s employee welfare benefit plan, which provided long-term disability (LTD) benefits, subject to the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001. Effective January 1, 2013, Oakwood switched the insurer responsible for that plan from Hartford to Reliance. Wallace took medical leave in October 2012, returning to work in April 2013. Wallace took medical leave again in May 2013 and has not returned to work. Reliance denied her claim for LTD benefits citing the pre-existing condition provision of its plan document and describing the review process, including that “failure to request a review within 180 days … may constitute a failure to exhaust the administrative remedies … and may affect ability to bring a civil action.” The plan document did not describe the review process or an exhaustion requirement. After discussions with Reliance, Wallace submitted an unsuccessful claim to Hartford. Wallace filed suit under ERISA. The district court granted Wallace judgment against Reliance based on the administrative record.The Sixth Circuit affirmed the denial of Reliance’s motion to dismiss on the basis of exhaustion. A plan document must detail claims review procedures and remedies. The court vacated the judgment on the record; further fact-finding is necessary to determine whether Wallace was eligible for LTD benefits and in what amount. Wallace may have been covered under transfer of insurance and pre-existing conditions limitation credit provisions, but the record does not permit a definitive finding. View "Wallace v. Oakwood Healthcare, Inc." on Justia Law

Posted in: ERISA
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Rebecca, employed by SNS, enrolled herself and her husband in SNS’s health-benefits coverage. In 2013, Rebecca fell at work and injured her knee. Her injury was too severe to permit her to continue working. She signed a form requesting to open a workers’ compensation claim and to receive a leave of absence. The form did not mention the “Family and Medical Leave Act.” SNS sent a letter instructing her to complete paperwork for processing her absence under the FMLA. She did so. SNS approved her leave of absence as FMLA leave (rather than paid leave) for the first 12 weeks, but did not give her any other written notice of that designation. SNS deducted her insurance contributions from her workers’ compensation checks. SNS notified Rebecca when her FMLA leave expired, stating that, if her employment was terminated, she could continue health benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Having received no premium payment weeks later, SNS notified Rebecca that the benefits had been discontinued. SNS terminated her employment. Rebecca sued, alleging that SNS failed to notify her of the right to temporarily continue health-benefit coverage under COBRA and breached its fiduciary duty under ERISA by failing to so notify her. The district court determined that a qualifying event occurred with the reduction in Rebecca’s work hours on the day after her injury, requiring notice. The Sixth Circuit reversed because the terms of Rebecca’s insurance coverage did not change upon her taking a leave of absence. No “qualifying event” occurred to trigger a COBRA notification obligation. View "Morehouse v. Steak N Shake" on Justia Law

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Knox-Bender suffered injuries from a car accident. She sought medical treatment at Methodist Healthcare. Methodist billed her $8,000 for the treatment. Payments to Methodist were made on Knox-Bender’s behalf by her employer-sponsored healthcare plan, her automobile insurance plan, and her husband’s healthcare plan. Knox-Bender says that the insurance plans had already agreed with Methodist on the price of her care. She claims that, despite this agreement, Methodist overcharged her and that this was common practice for Methodist. She and a putative class of other patients, sued in Tennessee state court. During discovery, Methodist learned that Knox-Bender’s husband’s healthcare plan was an ERISA plan, 29 U.S.C.1001(b) that covered $100 of her $8,000 bill. Methodist removed the case to federal court claiming complete preemption under ERISA. The district court denied Knox-Bender’s motion to remand and entered judgment in favor of Methodist. The Sixth Circuit reversed. The complete preemption of state law claims under ERISA is “a narrow exception to the well-pleaded complaint rule.” Methodist has not met its burden to show that Knox-Bender’s complaint fits within that narrow exception. Since Knox-Bender has not alleged a denial of benefits under her husband’s ERISA plan, ERISA does not completely preempt her claim. Even if Methodist had shown that Knox-Bender alleged a denial of benefits, it would also have show that Knox-Bender complained only of duties breached under ERISA, not any independent legal duty. View "K.B. v. Methodist Healthcare - Memphis Hospitals" on Justia Law

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Plaintiff filed suit against Safelite for breach of contract and negligent misrepresentation arising from the company's alleged mismanagement of its deferred compensation plan for executive employees. The Sixth Circuit affirmed the district court's grant of Safelite's motion for partial summary judgment, holding that the Safelite Plan qualifies as an employee pension benefit plan under 29 U.S.C. 1002(2)(A)(ii) and is not a bonus plan as defined in 29 C.F.R. 2510.3-2(c). Therefore, the Safelite Plan was not exempted from coverage under the Employee Retirement Income Security Act. View "Wilson v. Safelite Group, Inc." on Justia Law

Posted in: ERISA