Justia U.S. 5th Circuit Court of Appeals Opinion Summaries

Plaintiff appealed from the district court's dismissal of his suit alleging claims of equitable estoppel and breach of fiduciary duties pursuant to the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq. The district court dismissed the complaint for failure to state a claim. The court held that plaintiff stated a claim for relief that was cognizable under ERISA, in light of CIGNA Corp. v. Amara. Because relief was available under the surcharge doctrine under Amara, the court did not address the equitable estoppel claim and the district court was free to consider that claim on remand. Finally, the district court did not err in dismissing Defendant Entergy Mississippi where plaintiff failed to allege that Entergy Mississippi sponsored or administered the plan or made any decisions with respect to his benefits. View "Gearlds, Jr. v. Entergy Services, Inc., et al" on Justia Law

Plaintiff appealed the district court's grant of summary judgment to the Plan on his claim under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. Plaintiff asserted that the Plan did not comply with procedures set out by ERISA by changing its basis for denial on administrative appeal and by not identifying the independent physician reviewer who recommended denial on administrative appeal. Because plaintiff did not specify the failure to identify the physician in his amended complaint, the court did not address this issue. The court agreed with plaintiff, however, that the Plan did not substantially comply with ERISA procedures by changing its basis for denying coverage on administrative appeal. The court concluded that remand to the Plan for a full and fair review was appropriate. View "Rossi v. Precision Drilling Oilfield Svcs. Corp. Emp. Benefits Plan" on Justia Law

A third-party administrator of medical benefits plans, IMA, denied claims made on behalf of two patients who received treatment from the same medical provider, LifeCare. The court held that IMA incorrectly interpreted the plans because it categorized LifeCare as a skilled nursing facility (SNF) without finding that LifeCare "fully meets all of" the plans' seven SNF factors. IMA abused its discretion because categorizing LifeCare as an SNF without considering the seven-factors SNF test contradicted the plain language of the plans. The court found that the district court correctly held that LifeCare could maintain an action against IMA pursuant to 29 U.S.C. 1132(a)(1)(B) and that IMA was liable for exercising actual control over the claims process. The court further held that the district court did not abuse its discretion in awarding attorneys' fees. View "Lifecare Mgmt. Svcs., LLC v. Ins. Mgmt. Admins. Inc, et al" on Justia Law

Plaintiff, a former NFL player, filed suit seeking more generous disability benefits under the Bert Bell/Pete Rozelle NFL Player Retirement Plan. The district court granted summary judgment in favor of the Plan, affirming its benefits determinations that plaintiff was only eligible for "Inactive" player disability benefits instead of the more generous "Football Degenerative" disability benefits he sought. The court held that the district court did not err by applying abuse of discretion review to the Retirement Board's 2011 benefits determination; the district court did not err in using abuse of discretion instead of a heightened standard of review when considering the arbitrator's decision; and the district court's decision affirming the Retirement Board's 2006 and 2011 benefits determination on the merits under the abuse of discretion standard was correct. Accordingly, the court affirmed the district court's grant of summary judgment in favor of the Plan. View "Atkins v. Bert Bell/Pete Rozelle NFL, et al" on Justia Law

In this ERISA benefits case, the plan administrator (Appellant) appealed the district court's judgment that a deceased plan participant's stepsons, rather than his siblings, were entitled to the deceased's benefits. Appellant interpreted the term "children" as used in the plan to mean biological or legally adopted children. The Fifth Circuit Court of Appeals reversed, holding that the district court erred when it set aside Appellant's decision and granted judgment for the deceased's stepchildren, as (1) Appellant's interpretation of the term "children" was legally correct; and (2) nothing in the plan or ERISA required Appellant to incorporate the concept of equitable adoption into the plan definition of "children." View "Herring v. Campbell" on Justia Law

LINA appealed the decision of the district court holding that it abused its discretion in its denial of benefits to plaintiff under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. Plaintiff alleged that LINA wrongly denied her the benefits of her common-law husband's ERISA-governed Group Accident Policies where her husband participated in two accidental death and dismemberment policies. The court affirmed the district court's holding that the common law definition of "accident" adopted in Todd v. AIG Life Insurance Co., was controlling in all ERISA accidental death and dismemberment plans where the term "accident" was undefined, irrespective of whether the plan administrator was given discretion to interpret the plan. View " Firman v. Beacon Construction Co., Inc." on Justia Law

Plaintiff appealed the district court's summary judgment dismissing her suit to recover health insurance benefits under an employee plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001-1461. Aetna, a Texas health maintenance organization (HMO), provided and administered the plan's health insurance benefits under an agreement giving Aetna discretion to interpret the plan's terms. Aetna refused to reimburse plaintiff for care she received from a specialist outside of the Aetna HMO to whom she had been referred by a physician in the HMO. Aetna denied her claim because the referral was not pre-authorized by Aetna. The district court found as a matter of law that Aetna did not abuse its discretion in denying coverage. The court found, however, that the plan was ambiguous and the need for pre-authorization was not clearly stated in Aetna's summary description of the plan. And under the circumstances of the case, it could not be said as a matter of law that Aetna did not abuse its discretion in denying coverage. View "Koehler v. Aetna Health, Inc." on Justia Law

Plaintiffs brought an enforcement suit against defendants under the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001-1461. Plaintiffs alleged that defendants' practice of offering reimbursements for telephone services to retirees who lived outside of defendants' service region constituted a "pension plan" under ERISA. Judge Rodriquez was assigned to the claims at issue here and to Boos v. AT&T, a case involving similar claims. After ruling that the concession at issue in Boos was not a pension plan under ERISA, Judge Rodriquez reconsidered Judge Justice's interlocutory order with respect to plaintiffs' claims in this case. He concluded that the program of retirement benefits was not a pension plan under ERISA and he then entered a final judgment. Because the court concluded that Judge Rodriquez did not abuse his discretion by revising Judge Justice's interlocutory order, the court affirmed the judgment of the district court. View "Stoffels, et al. v. SBC Communications, Inc., et al." on Justia Law

ACS and FKI appealed the district court's decision to dismiss their suit for equitable relief under section 502(a)(3) of the Employee Retirement Income and Security Act of 1974 (ERISA), 29 U.S.C. 1132(a)(3)(B), for lack of jurisdiction. ACS and FKI argued that the district court: (1) erroneously interpreted two Supreme Court cases as requiring dismissal of their claims; (2) abused its discretion in denying their motion for a default judgment against one of the defendants; (3) should have concluded that Chapter 142 of the Texas Property Code was preempted by ERISA; and (4) should have deferred to the FKI Plan administrator's determination of liability. Pursuant to the three-part test in Bombardier Aerospace Emp. Welfare Benefit Plan v. Ferrer, Poirot, & Wansbrough, the court affirmed the district court's decision to dismiss the ERISA claims against Larry Griffin, Judith Griffith, Willie Earl Griffin (the Trustee), and the Larry Griffin Special Needs Trust for lack of jurisdiction. Accordingly, the court found it unnecessary to address the remaining arguments. View "ACS Recovery Services, Inc., et al. v. Griffin, et al." on Justia Law

This appeal arose from the district court's order dismissing plaintiffs' claim for lack of subject matter jurisdiction due to the Railway Labor Act's (RLA), 45 U.S.C. 151, 181, exclusive and mandatory dispute resolution process that applied to plaintiffs' claims. Plaintiffs argue that the RLA did not apply to them because they were no longer "employees" as contemplated by the RLA. Alternatively, plaintiffs argued that even if the RLA applied to them as former employees, they complied with the terms of their Collective Bargaining Agreement (CBA), which allowed them to bring an action in federal district court pursuant to section 501(a)(1)(B) of the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. The court held that plaintiffs were employees under the RLA pursuant to Supreme Court precedent. In the alternative, plaintiffs were explicitly looking for a "contracted-for" judicial remedy following an adverse RLA-established Retirement Board ruling without showing any of the narrow exceptions to RLA exclusivity. Therefore, the court declined to depart from established precedent preventing parties from creating federal court jurisdiction where there was none. Accordingly, the judgment was affirmed.