Justia U.S. 1st Circuit Court of Appeals Opinion Summaries

Plaintiff, an RN, stopped working at the hospital and went on disability only a few months after starting work. Her symptoms were attributed to chronic pancreatitis, chronic pain syndrome or fibromyalgia; she took "impressive amounts of narcotics" to manage her pain, which caused negative side effects. After about five years, the company terminated benefits, finding that she was not totally disabled, as defined by the policy. The district court upheld the termination in a suit under the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). The First Circuit remanded for further review, reasoning that plaintiff's activities, shown on surveillance tapes, and the lack of clinical documentation were overstated.

A employee made a series of attempts to obtain benefits under the company's long-term disability policy. A copy of the plan, which he obtained during internal appeals, contained no limitation on filing suit to challenge denials, but did reserve the right to make alterations to the plan. The plan was later amended to include a one-year limitation on bringing suit. Employee did not receive notice of the change. In 2005 the plan issued a final written rejection. In 2008 the employee filed suit under the Employee Retirement Income Security Act, 29 U.S.C. 1109 and 1132. The district court dismissed. The First Circuit reversed. While the plan did not engage in deceptive conduct that would implicate equitable estoppel, equitable tolling applies based on the failure to give notice of the change. The employee was reasonably diligent.

The company purchased a disability benefits plan, regulated by the Employee Retirement Income Security Act. A part-owner and employee of the company received benefits for about four years before the insurer terminated benefits because her non-salary income was higher than her salary income had been. The plan defines "pre-disability earnings" as: "your monthly rate of earnings from the employer in effect just prior to the date disability begins" and "basic annual earnings" as the amount reported by the policyholder on a W-2, excluding commissions. The company argued that a provision allowing termination of benefits when "current earnings" reach a percentage of pre-disability earnings referred to earnings from all sources. The district court held that the employee was not entitled to benefits but denied the insurer reimbursement. The First Circuit reversed, in favor of the employee, finding that the insurer's interpretation of the plan was unreasonable.