Justia U.S. 1st Circuit Court of Appeals Opinion SummariesArticles Posted in ERISA
Jette v. United of Omaha Life Insurance Co.
The First Circuit vacated the entry of summary judgment in this case brought by Plaintiff seeking relief from the termination of her benefits under the civil enforcement provision of the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(1), holding that Defendant did not provide Plaintiff a full and fair review of her claim, and Plaintiff was prejudiced by Defendant's procedural violation.Plaintiff participated in a long-term disability plan sponsored by her employer and funded and administrated by Defendant. The Plan was subject to ERISA. When Defendant terminated Plaintiff's disability benefits, Plaintiff filed an internal appeal review. Defendant upheld the termination of benefits, relying in part on a report written by a doctor hired by Defendant to examine Plaintiff. Plaintiff was not given a copy of the doctor's report. Plaintiff sought relief under ERISA's civil enforcement provision, arguing that, in failing to provide her with an opportunity to respond to the doctor's report, Defendant failed to provide her with a full and fair review, as required by ERISA and its implementing regulation. The district court granted summary judgment for Defendant. The First Circuit vacated the summary judgment, holding that Defendant committed a procedural violation, and Plaintiff was prejudiced thereby. View "Jette v. United of Omaha Life Insurance Co." on Justia Law
Ovist v. Unum Life Insurance Company of America
The First Circuit affirmed the judgment of the district court granting summary judgment to Defendant and dismissing Plaintiff's action brought under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq, holding that summary judgment was properly granted.Plaintiff was a participant in her employer's long-term disability plan, which was insured and administered by Defendant, Unum Life Insurance Company of America, and governed by ERISA. In 2011, Plaintiff was granted benefits under the plan. In 2015, Defendant terminated Plaintiff's benefits. Plaintiff brought this action seeking recovery and reinstatement of her benefits. The district court granted summary judgment for Defendant. The First Circuit affirmed, holding (1) Defendant's requirement that Plaintiff provide objective evidence of her functional limitations in order to avoid a limitation in the plan was reasonable; and (2) substantial evidence supported Defendant's determination that Plaintiff lacked objective proof in her functional limitations. View "Ovist v. Unum Life Insurance Company of America" on Justia Law
Wong v. FMR LLC
The First Circuit affirmed the judgment of the district court dismissing this putative class action complaint brought under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., holding that the district court did not err or abuse its discretion.Plaintiffs claimed that FMR LLC and several related Fidelity entities and affiliates (collectively, Fidelity) violated fiduciary duties it owed to its customer plans and their participants by exacting and retaining certain fees. The fees were exacted from mutual funds for the privilege of being placed on the menu of investment options Fidelity made available to 401(k) plans that contract with it to receive certain investment opportunities and services. The district court granted Fidelity's motion to dismiss for failure to state a claim. The First Circuit affirmed, holding that the district court properly dismissed the complaint. View "Wong v. FMR LLC" on Justia Law
Doe v. Harvard Pilgrim Health Care, Inc.
In this ERISA action, the First Circuit affirmed the rulings of the district court entering judgment for Defendants on remand and refusing to award Plaintiff attorneys' fees for her success on a prior appeal, holding that there was no clear error on the part of the district court.Plaintiff spent several months at a residential mental health treatment center. Defendants covered certain costs of Plaintiff's treatment but denied coverage for a four-month period on the grounds that Plaintiff could have stepped down to a lower level of treatment during that period. Plaintiff brought suit seeking de novo review of her claim for coverage of the four-month period under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001-1461. The district court entered summary judgment for Defendants. The First Circuit vacated the judgment and remanded so the district court could consider additional evidence. On remand, the district court again granted summary judgment for Defendants. The First Circuit affirmed, holding (1) it was not clear error for the district court to conclude that, at the beginning of the four-month period, Plaintiff's continued stay at the residential facility was not medically necessary; and (2) there was no clear error in the district court's decision not to award attorney's fees. View "Doe v. Harvard Pilgrim Health Care, Inc." on Justia Law
Coffey v. New Hampshire Judicial Retirement Plan
The First Circuit held that the New Hampshire Judicial Retirement Plan (Plan) does not allow a former judge who resigned with sufficient years of creditable service, but before reaching the minimum retirement age, to receive a Service Retirement Allowance (SRA) upon later reaching the retirement age.Plaintiff was fifty-four years old when she resigned from her position as a superior court justice for the state of New Hampshire. Plaintiff served in that position for sixteen-and-a-half years. At the age of sixty-one, Plaintiff applied for an SRA. The Board of Trustees of the Board of Trustees (Board) of the Plan denied her application. Plaintiff filed suit against the Plan seeking a declaratory judgment that she was eligible for an SRA. The district court granted summary judgment in favor of the Plan as to Plaintiff's claim for violation of N.H. Rev. Stat. 100-C, 5, concluding that the plain language of the statute requires a judge to be in active service when she elects to retire and claim a service retirement allowance. The First Circuit affirmed, holding that, under the circumstances of this case, Plaintiff was not eligible to receive an SRA on her application. View "Coffey v. New Hampshire Judicial Retirement Plan" on Justia Law
Arruda v. Zurich American Insurance Co.
In this insurance dispute, the First Circuit directed entry of summary judgment for Zurich American Insurance Company, holding that Zurich's decision to deny the insured's claim was supported by substantial evidence.Denise Arruda filed a claim for death benefits following the death of her husband, Joseph Arruda, in a car accident. Zurich denied the claim, concluding that Joseph's death was not within the coverage clause of the policy because the death was not independent of all other causes and that it was caused or contributed to by his pre-existing health conditions. Denise brought this action under 29 U.S.C. 1132(a)(1)(B) alleging that Zurich violated ERISA by denying the insurance benefits. The district court entered summary judgment in favor of Denise, concluding that substantial evidence did not support Zurich's decision. The First Circuit reversed, holding that Zurich's conclusion that Joseph's death was caused or contributed to by pre-existing medical conditions was not arbitrary or capricious and was supported by substantial evidence. View "Arruda v. Zurich American Insurance Co." on Justia Law
Martinez v. Sun Life Assurance Co. of Canada
The First Circuit affirmed the judgment of the district court in favor of Sun Life Assurance Company of Canada finding that Sun Life properly permitted an offset of Appellant's benefits under tis employer-sponsored long-term disability insurance policy (the Plan) by the amount of Appellant's service-connection disability compensation (Veterans' Benefits), holding that the district court did not err.Specifically, the First Circuit held (1) Appellant's Veterans' Benefits fell squarely within the definition of "Compulsory Benefit Act or Law"; (2) that the district court did not err by concluding as a matter of law that Veterans' Benefits unambiguously qualify as a form of "Other Income Benefit" covered by the Plan's offset provision; and (3) the district court did not err by rejecting as a matter of law Appellant's assertion that Sun Life's offset determination was motivated, at least in part, by Appellant's military service in violation of the Uniformed Services Employment and Reemployment Rights Act. View "Martinez v. Sun Life Assurance Co. of Canada" on Justia Law
Lavery v. Restoration Hardware Long Term Disability Benefits Plan
The First Circuit affirmed the judgment of the district court concluding that the denial of Plaintiff's disability benefits claim violated the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., holding that Aetna Life Insurance Company's decision to deny Plaintiff's benefits claim was arbitrary and capricious.Plaintiff employed for benefits under his employer's long-term disability benefits plan, which Aetna administered and funded, after Plaintiff was diagnosed with malignant melanoma. Aetna denied the application under the plan's exclusion for disabilities caused by pre-existing conditions. Plaintiff subsequently brought this action. The district court entered judgment for Plaintiff and awarded him back benefits, interest, fees, and costs. The First Circuit affirmed, holding that an unconflicted fiduciary would likely have found coverage. The Court remanded the case for any further proceedings that may be necessary. View "Lavery v. Restoration Hardware Long Term Disability Benefits Plan" on Justia Law
Santana-Diaz v. Metropolitan Life Insurance Co.
The First Circuit affirmed district court's grant of judgment in favor of Defendant Metropolitan Life Insurance Co. (MetLife) on Plaintiff's suit challenging the denial of long-term disability (LTD) benefits for Plaintiff under his employee welfare benefit plan (Plan), holding that MetLife's decision to deny LTD benefits to Plaintiff based on physical disability was reasonable and substantially supported by the evidence.MetLife, the Plan's administrator, denied Plaintiff's claim for benefits, concluding that the medical information provided by Plaintiff did not support the conclusion that Plaintiff was precluded from performing his job due to his medical conditions. After exhausting his administrative remedies, Plaintiff brought suit under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001-1461. The district court granted judgment on the administrative record to MetLife. The First Circuit affirmed, holding (1) MetLife adequately considered the conditions documented by Plaintiff's physician and physiatrist; (2) MetLife consistently interpreted the Plan; (3) MetLife provided Plaintiff with sufficient information regarding the requisite showing to qualify for LTD benefits; and (4) MetLife did not act in an arbitrary or capricious manner by considering the functional limitations of Plaintiff's condition. View "Santana-Diaz v. Metropolitan Life Insurance Co." on Justia Law
Fortier v. Hartford Life & Accident Insurance Co.
In this Employee Retirement Income Security Act (ERISA) suit, the First Circuit affirmed the district court's judgment finding that Plaintiff’s appeal from the expiration of her long-term disability (LTD) benefits was untimely and granting a motion for judgment on the administrative record for the disability insurer and the plan under which Plaintiff received the benefits, holding that the district court did not err.After Hartford Life and Accident Insurance Company (Hartford) gave notice to Plaintiff that the LTD benefits it had provided her under the Dartmouth Hitchcock Clinic Company Long Term Disability Plan (Plan) would expire, Plaintiff filed an untimely appeal. Plaintiff then brought this action arguing that even if the appeal was untimely, the untimeliness should be excused. The district court granted a motion for judgment on the administrative record for Hartford and the Plan. The First Circuit affirmed, holding (1) the ERISA regulation defining an “adverse benefit determination” requires that the 180-day time limit start from the date of notice of termination of benefits; (2) Hartford properly followed the terms of the Plan, which met the ERISA requirements; (3) the ERISA substantial compliance doctrine did not excuse Plaintiff’s untimely ERISA administrative appeal; and (4) the New Hampshire notice-prejudice rule did not apply to Plaintiff’s situation. View "Fortier v. Hartford Life & Accident Insurance Co." on Justia Law