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

In 2011, Michigan passed the Health Insurance Claims Assessment Act, Mich. Comp. Laws 550.1731–1741, to generate revenue needed to fund its obligations under Medicaid. The Act functions by imposing a one-percent tax on all “paid claims” by “carriers” or “third party administrators” to healthcare providers for services rendered in Michigan for Michigan residents. “Carriers” include sponsors of “group health plan[s]” set up under the strictures of the Employee Retirement Income Security Act, 29 U.S.C. 1002–1461. On top of the tax, every carrier and third-party administrator paying the tax must submit quarterly returns with to the Michigan Department of the Treasury and “keep accurate and complete records and pertinent documents as required by the department.” Every carrier and third-party administrator must also “develop and implement a methodology by which it will collect the [tax]” subject to several conditions. SIIA sought a declaratory judgment that ERISA preempted the Act, and an injunction, to prevent implementation and enforcement of the Act against the ERISA-covered entities. The district court dismissed, concluding that the Act did not offend ERISA’s express preemption clause because the Act did not “relate to” an ERISA-governed benefit plan. The Sixth Circuit affirmed, finding that the statute escapes the preemptive reach of ERISA.View "Self-Ins. Inst. of Am., Inc. v. Snyder" on Justia Law

Nationwide, with 32,000 employees in 49 states, has an ERISA employee-benefits plan that provides short-term disability (STD), long-term disability (LTD), and “Your Time” benefits. An employee can receive Your Time benefits for personal reasons, such as vacation or illness. To receive STD benefits, an employee must be “STD Disabled,” which means “a substantial change in medical or physical condition due to a specific illness that prevents an Eligible Associate from working their current position.” Specific rules govern maternity leave. The first five days of paid maternity leave come out of an associate’s Your Time benefits. Thereafter, a new mother is considered STD Disabled and entitled to STD benefits for six weeks following a vaginal delivery, or eight weeks following a cesarean section. Wisconsin’s Family Medical Leave Act requires that employers allow six weeks of unpaid leave following “[t]he birth of an employee’s natural child[.]” The Act’s “substitution provision” requires employers to allow an employee to substitute “paid or unpaid leave of any other type provided by the employer” for the unpaid leave provided by the statute. A Wisconsin Nationwide employee had a baby. She received six weeks of STD benefits under Nationwide’s plan. She then requested an additional period of STD benefits pursuant to the substitution provision. The plan denied the request, finding that she was no longer short-term disabled under the plan. The Wisconsin Supreme Court had held that, ERISA did not preempt the Wisconsin Act. The district court held that, under the Supremacy Clause, the administrator was required to comply with ERISA rather than the Wisconsin Act. The Sixth Circuit affirmed.View "Sherfel v. Newson" on Justia Law

Plaintiffs, salaried employees of Metal Container, participated in the Anheuser-Busch qualified defined-benefits pension plan under the Employee Retirement Income Security Act, 29 U.S.C. 1001-1461 (ERISA). The plan was amended in 2000 to add that upon a change in control, the retirement benefits of a participant “whose employment with the Controlled Group is involuntarily terminated within three (3) years after the Change in Control shall be determined by taking into account an additional five (5) years of Credited Service and ... an additional five (5) years of age.” The amendment followed management’s recognition that the plan was overfunded and might attract a potential acquirer. In 2008, InBev acquired Anheuser-Busch, including its subsidiary Metal Container, in a hostile takeover that was a “change in control” under the amendment. Plaintiffs continued working for Metal Container and remained employees of Anheuser-Busch’s Controlled Group until October 1, 2009, when InBev spun off Metal Container plants in a sale to Ball Corporation. Plaintiffs became employees of Ball. Plaintiffs sought recalculation of their future Anheuser-Busch retirement benefits, claiming that because their employment ended within three years of a change in control, they were entitled to enhanced benefits, regardless of the fact that Ball guaranteed them continued employment with substantially similar salary and benefits. Their claims were denied on the ground that they had not experienced unemployment. The district court dismissed their 29 U.S.C. 1132(a) claims of enhanced retirement benefits and breach of fiduciary duty. The Sixth Circuit reversed, finding the court’s reading of the 2000 amendment flawed. View "Adams v. Anheuser-Busch Co., Inc." on Justia Law

Central States, an employee benefit plan governed by the Employee Retirement Income Security Act, provides health insurance for Teamsters and their families. Guarantee Trust provides sports injury insurance for student athletes. Each of 13 high school and college athletes, all children of Teamsters, holds general health insurance from Central and sports injury insurance from Guarantee. Each suffered an injury while playing sports (most often football) between 2006 and 2009, and sought coverage from both companies. Each time Guarantee refused to pay the athlete’s medical expenses, and each time Central paid the bill under protest. The district court entered a declaratory judgment under ERISA, 29 U.S.C. 1132(a)(3)(B), that, when coverage of student athletes overlap, Guarantee must pay, and ordered Guarantee to reimburse Central for the payouts to the 13 students. The Sixth Circuit, affirmed in part characterizing the case as a “you first” paradox, or ‘gastonette.” An ERISA plan may coordinate benefits with another policy, but may not redefine the coverage of another policy. Absent the Central plan, the Guarantee policy would cover the sports injuries at issue without question. An ERISA plan must keep doing what it would do in another plan’s absence. That amounts to coordinating benefits, not redefining coverage. View "Cent St, SE & SW Areas Health & Welfare Fund v. First Agency, Inc." on Justia Law

Hi-Lex has about 1,300 employees. Blue Cross Blue Shield of Michigan (BCBSM) served as a third-party administrator (TPA) for Hi-Lex’s Health and Welfare Benefit Plan since 1991. Under the Administrative Services Contracts (ASCs) between the parties, BCBSM agreed to process healthcare claims for Hi-Lex employees and grant those employees access to BCBSM’s provider networks. BCBSM received an “administrative fee” set forth in ASC Schedule A on a per-employee, per month basis. In 1993, BCBSM implemented a new system, “retention reallocation,” to retain additional revenue. Regardless of the amount BCBSM was required to pay a hospital for a given service, it reported a higher amount that was then paid by the self-insured client. Hi-Lex allegedly was unaware of the retention reallocation until 2011, when BCBSM disclosed the fees in a letter and described them as “administrative compensation.” Hi-Lex sued, alleging breach of fiduciary duty under the Employee Retirement Income Security Act, 29 U.S.C. 1104(a). The court awarded Hi-Lex $5,111,431 in damages and prejudgment interest of $914,241. The Sixth Circuit affirmed that: BCBSM was an ERISA fiduciary and breached its fiduciary duty under ERISA section 1104(a), that BCBSM conducted “self-dealing” in violation of section 1106(b)(1), and that Hi-Lex’s claims were not time-barred. View "Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of MI" on Justia Law

The Employee Retirement Income Security Act prohibits an employer from retaliating against an employee “because he has given information or has testified or is about to testify in any inquiry or proceeding relating to [the Act],” 29 U.S.C. 1140. Sexton made a one-time unsolicited internal complaint to his employer about alleged violations of the ERISA, with respect to seating employees on the company’s board of directors. About six months later, the company fired Sexton from his job as a general manager. Sexton sued in Michigan state court for violating the state Whistleblower Protection Act and for breaching his employment contract. The company invoked complete preemption under ERISA and removed the case to federal court. Sexton did not challenge the company’s removal of the case or its use of complete preemption. The district court granted the company summary judgment on the ERISA claim and declined supplemental jurisdiction over Sexton’s breach-of-contract claim. The Sixth Circuit affirmed, holding that Sexton’s complaint did not amount to “giv[ing] information ... in any inquiry” under ERISA. View "Sexton v. Panel Processing, Inc." on Justia Law

Plaintiffs worked until 2006, when the plant closed, and retired under a collective bargaining agreement (CBA); that provided that the employer would provide health insurance, either through a self-insured plan or under a group insurance policy and identified the employer’s contribution to the premium. The CBAs provided that the coverage an employee had at the time of retirement or termination at age 65 or older other than a discharge for cause “shall be continued thereafter provided that suitable arrangements for such continuation[] can be made… In the event… benefits … [are] not practicable … the Company in agreement with the Union will provide new benefits and/or coverages as closely related as possible and of equivalent value." In 2011 TRW (the employer’s successor) stated that it would discontinue group health care coverage beginning in 2012, but would be providing “Health Reimbursement Accounts” (HRAs) and would make a one-time contribution of $15,000 for each eligible retiree and eligible spouse in 2012, and in 2013, would provide a $4,800 credit to the HRAs for each eligible party. The HRAs shifted risk, and potentially costs, to plaintiffs. TRW did not commit to funding the HRAs beyond 2013. Plaintiffs sued, claiming that the change breached the CBAs, in violation of the Labor-Management Relations Act, 29 U.S.C. 185, and the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court certified a class and granted summary judgment, ruling that the CBAs established a commitment to lifetime health care benefits. The Sixth Circuit affirmed View "United Steel, Paper, Forestry, Rubber, Mfg. Energy, Allied Indus. & Serv. Workers Int'l Union v. Kelsey-Hayes Co." on Justia Law

Nicole discovered Shawn’s body in their Ohio home. Shawn had gone out drinking the night before, while Nicole spent the night at a friend’s house. The Medical Examiner’s Office reported the cause of death as “[a]sphyxia by extreme and restricted position (positional asphyxia)” and the manner of death as “[a]cute ethanol intoxication ... ACCIDENT: Prolonged and extreme hypertension of neck and torso while intoxicated.” Shawn’s blood-alcohol level at the time of autopsy was .22%. Nicole filed a $212,000 claim for accidental-death benefits with the Plan, which covers “injury” as a result of an “accident,” defined as “an unintended or unforeseeable event or occurrence which happens suddenly and violently.” No benefits will be paid if the “Covered Person [is] deemed and presumed, under the law of the locale … to be under the influence of alcohol or intoxicating liquors.” Nationwide directed denial of Nicole’s claim, citing Exclusion 12, but quoting an earlier version that provided: “The Covered Person being deemed and presumed … to be driving or operating a motor vehicle while under the influence…” Later, based on amended Exclusion 12, Nationwide upheld the denial; its appeals panel affirmed. Nicole filed suit, asserting claims under the Employee Retirement Income Security Act and a common-law breach-of-fiduciary-duty claim. The district court entered judgment in favor of the defendants, but agreed with Nicole that the appeals panel had breached its statutory duty to provide her with Plan-related documents upon written request, and imposed a penalty of $55 per day ($8,910). The Sixth Circuit affirmed. View "Cultrona v. Nationwide Life Ins. Co." on Justia Law

The employers were formerly contributing members of the Teamsters Local Union No. 293 Pension Plan. In 2007-2008 each employer reached an agreement with the Plan to terminate its membership. They were required to pay, and have paid, “withdrawal liability” reflecting each employer’s share of unfunded, vested pension benefits under the Multiemployer Pension Plan Amendments Act, 29 U.S.C. 1381–1461. Under the Act, if the plan is terminated altogether by a “mass withdrawal” of the remaining members within three years, the earlier withdrawing members may be subject to additional “reallocation liability.” Disputes about the amount of such reallocation liability are subject to mandatory arbitration. The employers claim that a 2009 mass withdrawal was expedited to occur within the three-year period in order that they would be subject to reallocation liability. The Plan trustees sought more than $12 million in additional funds from the employers. The district court dismissed their suit for failure to complete arbitration. The Sixth Circuit affirmed. The Act requires that the claim of “sham” mass withdrawal be arbitrated. View "Knall Beverage, Inc. v. Teamsters Local Union No. 293 Pension Plan" on Justia Law

Javery began working for Lucent as a software engineer in 1998 and participated in Lucent’s Employee Retirement Income Security Act, 29 U.S.C. 1001, qualified disability plan, administered by CIGNA. In November 2002, he reported back pain. His family doctor, Dr. Dorado, prescribed medicine and testing, and recommended some time off work. In January 2003, after Lucent transferred him from Ohio to Illinois, Javery sought treatment from another physician, Seymour. The pain worsened. In May 2005, Javery stopped working on Dr. Seymour’s advice. Lucent approved and paid short term disability benefits from until those benefits expired in November 2005. Lucent notified CIGNA that it believed Javery might be eligible for long term benefits. Javery applied, submitting extensive medical evidence of his pain and resulting cognitive impairment and of his successful application for Social Security disability benefits, but the claim was denied. In addition to claiming that Javery had not shown that he was “disabled” as that term is defined in the Plan, CIGNA claimed that Javery should be judicially estopped from pursuing his ERISA claim because Javery failed to disclose the claim in his Chapter 13 personal bankruptcy action. The district court upheld the denial. The Sixth Circuit reversed. View "Javery v. Lucent Tech., Inc. Long-Term Disability Plan" on Justia Law