Well, we are finally in the throes of Fall and loving every minute of it -- cool crisp weather, Saturday football games and those Autumn colors - what's not to love? I don't know about you, but our summer in the South was hot and dry -- so much so that we experienced a drought until just recently. Our Courts, however, did not experience a drought of ERISA cases. This issue of the GWB e-RISA Newsletter focuses on several of the decisions reached over the long hot summer. As always, we encourage you to contact us if you have any questions about these cases or if we can provide any other assistance to you. Happy Fall!
FIRST CIRCUIT
Preemption Colonial Life & Accident Ins. Co. v. Medley, 2009 WL 1942070 (1st Cir. July 8, 2009): Calderon was a participant under an employee welfare benefit plan, which provided certain short-term benefits. The STD plan excluded coverage for "psychiatric or psychological condition[s] including but not limited to affective conditions, neuroses, anxiety, stress and adjustment reactions." Colonial insured the benefits provided under the plan. Calderon submitted a claim for STD benefits with alleged disability of major depressive disorder, panic disorder, and grief reaction. Colonial denied Calderon's claim based on the psychiatric or psychological condition provision. Calderon then filed a Charge of Discrimination with the Massachusetts Commission Against Discrimination (MCAD) alleging that by providing STD benefits to persons with physical, but not mental, disabilities was discriminatory and a violation of state law anti-discrimination law and the ADA.
Calderon's prior employer, UMass, and Colonial filed the underlying action seeking a declaratory judgment that Calderon's state law claims were preempted by ERISA and further investigation by MCAD must be enjoined. The district court agreed and enjoined MCAD's investigation. Calderon and MCAD appealed. On appeal, the First Circuit first determined that since all three elements of the Younger abstention doctrine were met, the district court should have abstained unless an exception applied. The district court had found that because preemption was "facially conclusive," an exception to abstention did apply. The district court made this determination by delving into the determination whether the ADA would be applicable to Calderon's state law claims. The First Circuit disagreed with the district court stating that the existence of a question of first impression regarding the ADA's applicability to Calderon's state law claims precludes preemption from being "facially conclusive." Further, the First Circuit held that MCAD had jurisdiction to conduct its investigations and that the district court's preliminary injunction must be reversed. The Court directed the district court to either dismiss the declaratory judgment action or stay further proceedings until MCAD entered a final ruling on the charges before it.
* Significantly, Medley provides that because it was an issue of first impression [the applicability of the ADA to the state law claims], it was not "facially conclusive" that the state law claims were preempted by ERISA. Plan administrators and insurers should be aware of this argument and the potential that ERISA may not preempt such novel claims.
SECOND CIRCUIT
Pre-existing Condition
In Cohen v. Metropolitan Life Ins. Co., 2009 WL 1605139 (2d Cir. June 9, 2009) (unpublished): In this case, MetLife appealed the decision of the district court that its denial of Cohen's application for LTD benefits based on the pre-existing condition plan provision was arbitrary and capricious. The Second Circuit affirmed the decision noting that MetLife's denial was based on the finding that during the exclusionary period, "Cohen sought medical advice or treatment for several of the symptoms which she states caused her to be unable to work." The condition that Cohen alleged prevented her from working was Chronic Fatigue Syndrome (CFS). The Court held that the symptoms associated with CFS were common and attributable to many different underlying conditions. Additionally, the Court found it significant that MetLife did not get a physician to review Cohen's file to determine whether the CFS symptoms she described derived from the same underlying aliments for which she received treatment during the exclusionary period despite "significant evidence in the record from treating physicians suggesting that the earlier symptoms were not attributable to Chronic Fatigue Syndrome." Taking into account MetLife's conflict of interest, the Court held that the district court did not err in finding that MetLife's determination was arbitrary and capricious.
* This decision instructs administrators that when basing a denial upon a "pre-existing condition," the record should reflect that the administrator considered and evaluated whether the treatment during the exclusionary period was, in fact, connected to the alleged disability.
Statute of Limitations Burke v. PricewaterhouseCoopers LLP Long Term Disability Plan, 2009 WL 1964972 (2d Cir. July 9, 2009): Burke was a participant under a long-term disability benefits plan established by PricewaterhouseCoopers and insured by Hartford. Burke filed a claim for long-term disability benefits and benefits were approved to commence at the expiration of her STD benefits on October 20, 2002. On March 28, 2003, Hartford requested a Proof of Loss. The Plan provided that a response to the Proof of Loss had to be submitted within 30 days of the request. Burke submitted this information on April 25, 2003. However, Hartford requested further information to be submitted by May 5, 2003. Burke did not provide this requested information and on May 12, 2003, Hartford terminated her benefits. Burke appealed and Hartford upheld its decision on October 2, 2003. Approximately three years later, on September 25, 2006, Burke filed the underlying action. The district court dismissed Burke's action as time-barred.
The issue on appeal was the "starting point [of] the applicable limitations period." The Plan provided a three-year limitations period and barred a claimant from bringing legal action more than three years after the time the Proof of Loss is required to be furnished, April 28, 2006 in this action. The Second Circuit acknowledged that while district courts in that Circuit used two different methods of calculating when an ERISA claim accrues-(1) when benefits are initially denied and (2) when administrative remedies have been exhausted-"New York law permits the Plan to begin the limitations period before a plan beneficiary can bring suit ..." Further, the Court stated that the fairness concerns that created the rule that an action does not accrue until all administrative remedies have been exhausted were less of a concern as a result of the DOL regulations concerning when plan administrators must decide an appeal. Finally, the Court recognized that rules of contract law that unambiguous terms may not be rewritten apply to ERISA plans. The Second Circuit affirmed the decision of the district court holding that it "join[s] the Fifth, Sixth, Seventh, and Eighth Circuits in upholding written plan terms including limitations periods which may begin to run before a claimant can bring a legal action."
* Burke establishes that the Second Circuit, like the Fifth, Sixth, Seventh and Eighth, will enforce written terms in ERISA plans, including terms that dictate an accrual period before a claimant can bring a legal action.
THIRD CIRCUIT
Interpretation of Plan Language; SPD versus Plan Language Delso v. Trustees of the Retirement Plan for the Hourly Employees of Merck & Co., 2009 WL 1928388 (3d Cir. July 7, 2009) (unpublished): Prior to his death, Delso was a participant under a retirement plan for hourly employees of Merck & Co. On December 24, 2002, while hospitalized, Delso signed an application declaring his intention to go on disability retirement immediately and requesting a lump sum payment of his pension under the plan. Delso died on December 26, 2002 at 6:14 a.m. Later that same day, Delso's union representative delivered his application to Merck's human resources department. The administrator denied Delso's application because his application was received after his death and the summary plan description provided that the application had to be delivered "while alive." Delso's wife appealed this decision but the administrator upheld its decision on appeal. Delso's wife then filed the underlying action. The district court found that the administrator had not acted arbitrarily or capriciously and granted summary judgment in favor of the administrator.
On appeal, the Third Circuit agreed with the district court. The Court first stated that "[i]n cases where an SPD conflicts with a main plan document, [it] ordinarily enforce[s] the terms of the SPD." The Court then found that the SPD and main plan documents did not conflict as the main plan document was silent on how the application had to be presented to the company. Finally, the Court pointed out that the SPD language did not reduce any rights or benefit of the participant; therefore, the administrator's interpretation was reasonable.
* Delso reinforces the rule in the Third Circuit that where the language in the SPD does not conflict with the main plan document and does not reduce the rights or benefits of participants, the SPD terms will be enforced.
Pre-existing Condition
In Doroshow v. Hartford Life and Accident Ins. Co., 2009 WL 2257384 (3d Cir. July 30, 2009), the Third Circuit held that Hartford's denial of plaintiffss claim for LTD benefits arising from a diagnosis of ALS was not arbitrary and capricious where an office visit note from plaintiff's treating physician during the policy look-back period indicated that plaintiff suffered from a motor neuron disease, but that the diagnosis was not felt to be ALS.
The plan at issue defined a pre-existing condition as "a condition for which medical treatment or advice was rendered, prescribed or recommended within 12 months (3 months for exempt employees) prior to Your effective date of insurance." The plan did not define the term "advice," but under an arbitrary and capricious standard of review, the Court held that Hartford was reasonable in finding that plaintiff received advice regarding ALS during the relevant period. The Court explained that although "we do not find generally that ruling out a condition constitutes advice or treatment for that condition, we find Dr. Goldstein's notes related to ALS particularly compelling in the broader context of [plaintiff's] entire medical history," which included consideration of ALS as a possible diagnosis for the range of symptoms plaintiff experienced in the years preceding his actual diagnosis.
* Doroshow provides an insightful discussion of when a pre-existing condition exclusion may be triggered by treatment or advice that rules out a condition or disease as a diagnosis and a disability is later claimed as a result of that same condition. The Doroshow court contrasted plaintiff's situation, which it described as a "suspected condition without a confirmatory diagnosis," which may appropriately be deemed a pre-existing condition, with "a misdiagnosis or an unsuspected condition manifesting non-specific symptoms," which would not be demonstrative of a pre-existing condition.
FOURTH CIRCUIT
Conflicting Evidence of Disability and Reliance on Reviewing Physician's Opinions Spry v. Eaton Corp. Long Term Disability Plan, 2009 WL 1524934 (4th Cir. June 2, 2009) (unpublished), the Fourth Circuit reversed the district court's ruling that Eaton abused it discretion by terminating plaintiff's claim for LTD benefits. In doing so, it held that resolving a conflict regarding whether objective evidence demonstrated that plaintiff was disabled was the administrator's responsibility. It also held that there was nothing inherently unreasonable in Eaton's decision not to adopt the opinions of plaintiff's primary care physicians, which conflicted with the opinions of Eaton's reviewing physicians, especially where new information emerged after the treating physicians rendered their opinions.
In so holding, the Court rejected the district court's conclusion that the administrator failed to give adequate consideration to the fact that plaintiff was approved for SSDI benefits, explaining that the denial letter specifically referenced the Social Security decision, indicating that it was considered. The SSA's determination, according to the Court, did not require Eaton to decide, "based on updated information and additional medical opinions, that plaintiff remained unable to work more than five years later." The Court also rejected plaintiff's argument that each of the medical opinions on which Eaton relied was flawed in that they did not assess all of plaintiff's conditions (since each physician limited his/her review to the condition(s) within his/her specialty). The Court explained that Eaton was not limited to considering the opinions of only those physicians who addressed all of plaintiff's conditions. Rather, "[t]he critical point is that the Administrator consider all of the conditions. And, nothing in the record suggests that the Administrator relied on any physician's opinion for a proposition broader than the opinion that physician rendered."
* Spry is an interesting opinion in that it reiterates, even in the wake of Glenn, that where reasonable minds may differ as to the weight and significance of conflicting evidence, the administrator's decision - as long as supported by sufficient evidence in the record - is likely reasonable and should not be disturbed.
SIXTH CIRCUIT
ERISA Safe Harbor Provision; Physical Exam v. File Review; Consideration of Effect of Stress Helfman v. GE Group Life Assurance Co., 2009 WL 2191516 (6th Cir. Jul. 24, 2009): Helfman was employed by two family construction businesses, Atlas Filmore and Fairway. Fairway had coverage for its employees under a plan of benefits issued by Genworth and Filmore had coverage for its employees under a plan of benefits issued by Sun Life. In January 2004, Helfman applied for long term disability benefits from both Genworth and Sun Life after suffering multiple cardiac episodes in late 2003. Helfman was awarded long term disability benefits from both Genworth and Sun Life. In January 2005, Sun Life and Genworth learned that Helfman was receiving benefits from both companies. Thereafter, in March 2005, Genworth terminated benefits finding that he was no longer eligible to receive benefits because Sun Life's benefits qualified as "other income" pursuant to the Genworth plan. In May 2005, Sun Life terminated benefits finding that Helfman no longer met the definition of disability pursuant to the Sun Life plan.
Helfman exhausted his administrative remedies with both companies and then filed suit in Michigan state court for benefits. Sun Life removed the case, with the consent of Genworth, to the Eastern District of Michigan. Sun Life and Genworth asserted that ERISA standards applied to Helfman's claims. Helfman argued that the safe harbor exception applied. The district court disagreed with Helfman, applied ERISA standards to his claims and found that neither of the defendant's decisions to terminate benefits were arbitrary or capricious. Helfman appealed.
The Sixth Circuit first addressed Helfman's argument that since he reimbursed both companies for his premiums, he satisfied the first criterion of ERISA's safe harbor provision, which exempts from ERISA certain insurance programs. The Sixth Circuit agreed with the district court and held that because Helfman's employer contributed to premiums on behalf of the majority of employees, the first criterion could not be met irrespective of the fact that Helfman himself reimbursed his companies for premiums.
The next issue the Court addressed was whether Sun Life abused its discretion in terminating benefits. The Court found that Sun Life had in fact abused its discretion for several reasons. First, the fact that the Sun Life plan expressly reserved the right to conduct a physical exam and Sun Life instead conducted a file review "raise[d] questions about the thoroughness and accuracy of its review of [Helfman's] claim." Second, because the terms of the plan did not preclude prophylactic factors from consideration when determining whether an employee could perform his occupation, Sun Life's rejection of the effect of stress on Helfman's ability to work showed that Sun Life's decision was arbitrary and capricious. Finally, the Court held that "where an administrator exercises its discretion to conduct a file review, credibility determinations made without the benefit of a physical examination support a conclusion that the decision was arbitrary" The Court remanded to the district court with instructions to remand to the administrator to provide a full and fair review.
* Helfman's discussion of the Safe Harbor provision is instructive as it focuses on the plan as a whole as opposed to the particular plaintiff's participation in the plan. The case is also noteworthy with respect to the conclusion that an abuse of discretion could be found if a physical exam is not performed when the plan has the right to perform such an exam and if subjective complaints are disregarded when consideration of such complaints are not precluded by the terms of the plan.
SEVENTH CIRCUIT
Termination of Benefits by Amendment of Plan and Standard of Review Marrs v. Motorola, Inc., 2009 WL 2477650 (7th Cir. Aug. 14, 2009): In this case the Seventh Circuit held that the plan administrator's termination of benefits after payment for six years was reasonable under an amendment that limited benefits resulting from "mental, nervous, alcohol [or] drug-related" conditions, where the Plan had previously imposed no limit on the receipt of such benefits. Plaintiff argued that application of the amendment violated a plan provision that stated that no amendment "shall adversely affect the rights of any Participant to receive benefits with respect to periods of Disability prior to the adoption date of the amendment." The Court held that the administrator's interpretation of the provision and application of the amendment was reasonable where it paid plaintiff an additional two-years of benefits after the effective date of the amendment before termination.
The Court rejected Plaintiff's argument that Glenn required "'a more penetrating inquiry into the actions of a conflicted administrator' than the earlier case law." The Court recognized the distinction between cases involving the interpretation of plan documents and those involving application of a plan's criteria for an award of benefits to particular facts, explaining that the interpretation of contracts is generally a question of law to be resolved without deference to the decision-maker. It held, nonetheless, that "when an ERISA plan gives the plan administrator discretion to interpret its terms as well as to determine eligibility for benefits under terms the meaning of which is not questioned, the court can...reject the administrator's interpretation only if it is unreasonable." The Court explained further, "although, generally, ambiguities in an insurance policy are construed in favor of an insured, in the ERISA context in which a plan administrator has been empowered to interpret the terms of the plan, this rule does not obtain." Ultimately, the Court concluded that "the Glenn decision [does not have] the significance that [plaintiff] attaches to it even if it is fully applicable to cases involving the interpretation of plan amendments alleged to infringe on vested rights."
* In reviewing the Marrs Court's analysis, it is important to note that the plan itself addressed the effect of potential plan amendments. The Court relied heavily on the reasonableness of the administrator's interpretation of that plan provision in upholding the application of the amendment, rather than the reasonableness of the amendment itself.
Fiduciary Duties owed to an Administrator by the Fiduciary Sharp Electronics Corp. v. Metropolitan Life Ins. Co., 2009 WL 2501789 (7th Cir. Aug. 18, 2009): Rudzinski was a full-time employee of Sharp and a participant under a plan of benefits underwritten by MetLife. Sharp was the plan administrator and MetLife was the plan fiduciary. On April 2, 2002, as a result of chronic fatigue, joint pain and headaches, Rudzinski ceased employment with Sharp. Thereafter, she began receiving STD benefits paid by Sharp. Rudzinski also filed a claim for LTD benefits with MetLife. On July 9, 2002, Sharp notified Rudzinski that if she did not return to active employment, she would lose her job and Sharp would cease making payments on her behalf for LTD benefits with MetLife. Alternatively, Sharp notified Rudzinski that she could preserve her benefits with MetLife by obtaining a conversion policy and paying premiums on her own behalf. Rudzinski applied for a conversion policy and paid the applicable premiums. Thereafter, MetLife denied her claim for LTD benefits on the grounds that she had a pre-existing disability at the time she applied for the conversion policy. Rudzinski filed suit against MetLife.
During settlement negotiations, MetLife's lawyer stated to Rudzinski that another reason she did not qualify for benefits was that Sharp had discontinued payments for LTD premiums following the termination of her employment. Thereafter, Rudzinski amended her complaint naming Sharp as an additional defendant. In response, Sharp asserted a cross-claim against MetLife alleging breach of fiduciary duties.
Sometime later, Rudzinski dismissed her claims against Sharp and Rudzinski and MetLife settled. The only remaining claims were Sharp's breach of fiduciary claims against MetLife. The district court granted MetLife's motion to dismiss and Sharp appealed. The main issue on appeal was whether MetLife owed any fiduciary duties to Sharp. The Seventh Circuit agreed with the district court holding that pursuant to ERISA, MetLife and Sharp were both fiduciaries with respect to the plan but were not fiduciaries with respect to one another. The Court stated that their relationship was purely contractual-MetLife agreed to perform certain services for Sharp with respect to the Plan. Therefore, MetLife did not owe Sharp any fiduciary duties-"Sharp is not the kind of entity that Congress had in mind for the protection it created in ERISA." The Court affirmed the decision of the district court.
* Significantly, Sharp holds that a plan administrator does not have a cause of action against a plan fiduciary for breach of fiduciary duty as no fiduciary duties are owed.
TENTH CIRCUIT
Conflicting Evidence of Plan Beneficiaries Smith v. New Mexico Coal 401(K) Personal Savings Plan and USA Retirement Savings Plan, 2009 WL 1598454 (10th Cir. June 9, 2009) (unpublished): Smith brought an action under 29 U.S.C. Section 1132(a)(1)(B) against defendants claiming that defendants wrongfully paid her husband's children benefits instead of her as surviving spouse. Smith's husband, Begay, worked for a subsidiary of BHP Billiton and during his employment enrolled in a retirement savings plan and a personal savings plan ("he Plans"). Upon Begay's death on December 6, 2004, his children submitted claims for benefits. On March 24, 2005, Smith submitted a "Stipulation for Validation of Marriage" to the Plans in support of her claim for benefits. Notwithstanding the receipt of this Stipulation, the Plans paid Begay's benefits to his children finding that Begay had no surviving spouse. Then, on August 7, 2006, Smith and Begay's marriage was validated. The district court found that the decision to pay benefits to Begay's children was reasonable and supported by substantial evidence and that until August 7, 2006 when the marriage was validated, it was logical and reasonable for the Plans to conclude there was insufficient evidence to conclude that Smith was Begay's spouse. Smith appealed.
On appeal, the Tenth Circuit had to determine whether the decision to pay Begay's children was reasonable. The Court first stated that fiduciaries cannot "shut their eyes to readily available information when the evidence in the record suggests that the information might confirm the beneficiary's theory of entitlement and when they have little or no evidence in the record to refute that theory." The Court held that as of March 24, 2004, when it received Smith's "Stipulation for Validation of Marriage," it was unreasonable for the administrator to have paid from the Plans to Begay's children because there was conflicting evidence in the record whether Begay had a spouse who, pursuant to the terms of the Plan, would be entitled to benefits before his children. The Court reversed and remanded for an entry of summary judgment in favor of Smith.
* Administrators faced with conflicting evidence in the record regarding the beneficiaries of benefits should resolve the conflict prior to paying benefits or its decision is subject to review and, based on Smith, may be found to be unreasonable.
Combination of Factors Method of Review and Evidence that Mitigates Conflict of Interest Factor
In Holcomb v. Unum Life Ins. Co. of Amer., 2009 WL 2436673 (10th Cir. Aug. 11, 2009), the Tenth Circuit identified steps taken by a conflicted plan administrator which may reduce the significance or impact of the conflict of interest factor in the Court's analysis of whether it abused its discretion under the combination of factors method of review set forth in Glenn. It explained that Unum took steps to reduce its inherent bias by hiring two independent physicians and, therefore, the conflict-of-interest factor was afforded limited weight in the Court's evaluation. Specifically, the Court found that Unum "diligently endeavored to discover the nature of [plaintiff's] ailments" by routinely requesting updated medical records and conducting clinical reviews of the records and then soliciting expert evaluations from independent examiners - all while Unum continued to pay benefits. In addition, when Unum's nurse reviewer observed that plaintiff's treating physician's recommendations were inconsistent with the exam findings contained in the record, Unum did not rely solely on her determination but requested an independent evaluation from an outside physician.
* Since Glenn, there has been much debate over the relative weight of a fiduciary's presumed or structural conflict of interest. Holcomb articulates some of the ways in which an administrator may reduce the weight afforded that factor in the Court's review for abuse of discretion.
OTHER CIRCUIT COURT OPINIONS
Discovery Tholke v. Unisys Corp., 2009 WL 1773196 (2d Cir. June 23, 2009), involved a decision by the Second Circuit, in an earlier opinion, to remand this matter back to the district court to verify that the meeting minutes, which were relied upon by the district court in upholding the denial of Tholke's benefits, accurately reflected the opinion of the physician who opined that plaintiff could perform the duties of her own occupation and to determine the merits of the case. On remand, the district court limited discovery to whether the minutes accurately reflected the physician's opinion and granted summary judgment in favor of defendants. On appeal, the Second Circuit found that the district court's limited discovery was appropriate because it had given the district court explicit instructions to reexamine the accuracy of the minutes. Further, the Second Circuit reaffirmed the district court's grant of summary judgment because the defendants considered Tholke's job description along with the medical testimony of several doctors.
Appeal Gerhardt v. Liberty Life Assurance Co., 2009 WL 2178332 (8th Cir. Jul. 23, 2009): The issue in Gerhardt was whether the district court's reversal of Liberty's denial of benefits and remand of the claim to Liberty for further proceedings was a "final judgment." Liberty asserted that the remand was a final judgment and, therefore, appealable. Gerhardt argued that it was not a final judgment and, therefore, not appealable. The Court agreed with Gerhardt because (1) there was no clear and unequivocal manifestation by the trial court that its order ended the case, (2) the remand was not to a federal agency, (3) what Liberty was instructed to consider on remand is integral to the merits of Gerhardt's claim, and (4) the district court concluded that Liberty had to reconsider Gerhardt's claim and not that Gerhardt was eligible for benefits.
Adequacy of Explanation of Decision Love v. Nat. City Corp. Welfare Benefits Plan, 2009 WL 2178667 (7th Cir. Jul. 23, 2009): In this case, the Seventh Circuit addressed whether Liberty Mutual had set forth specific reasons for its denial in compliance with ERISA. The Court remanded Love's claim back to Liberty Mutual because neither Liberty Mutual's peer reviewer nor its denial letter addressed contrary findings of Love's treating physicians.
Exempt Plans Koval v. Washington County Redevelopment Authority, 2009 WL 2182843 (3d Cir., Jul. 23, 2009): In Koval, the Third Circuit decided that it would employ the NLRB analysis to determine whether an entity is a "governmental plan" exempt from ERISA. The NLRB test "looks at whether an entity is 'created directly by the state, so as to constitute departments or administrative arms of the government,' or 'administered by individuals who are responsible to public officials or to the general electorate.'" 402 U.S. 600 (1971).
Standard of Review Fischer v. Liberty Life Assurance Co., 2009 WL 2366115 (7th Cir. Aug. 4, 2009): The Court affirmed the holding of the district court which found that Liberty's decision that Fischer's claim was subject to the mental illness limitation was not arbitrary and capricious. The Court held that Fischer cannot prevail on an arbitrary and capricious standard of review because Liberty only has to show rational support in the record for its decision. Further, the Court found that while Fischer presented substantial evidence that his condition was physical, it was not an abuse of discretion for Liberty to reject this evidence in favor of contrary evidence that his disability was psychological.
Applicability of ERISA Lone Star OB/GYN Associates v. Aetna Health Inc., 2009 WL 2501340 (5th Cir. Aug. 18, 2009): Lone Star involved a dispute over the rate of payment provided in an agreement between Lone Star, a healthcare provider, and Aetna Health, administrator of several ERISA governed plans, which dictated Aetna Health's reimbursement for medical services provided to patients treated by Lone Star. The issue was whether ERISA governed this dispute. The Court held that although the agreement between Lone Star and Aetna Health referred to the ERISA governed plans that Aetna Health administered, ERISA was inapplicable because the dispute was over whether Aetna Health paid the correct rate and did not involve a determination of coverage under the plans.
Class Certification Dobson v. Hartford Financial Serv. Group, 2009 WL 2501930 (2d Cir. Aug. 18, 2009): Dobson was receiving long term disability benefits when Hartford suspended payments as a result of lack of proof of continuous disability. After a year of Dobson submitting proof of disability, Hartford reinstated benefits and made a lump sum back payment, without interest. Dobson brought suit on behalf of himself and those similarly situated whose benefits were paid out beyond relevant time periods. Dobson moved for class certification. The district court denied his motion and the Second Circuit agreed. The Court stated that the proposed class failed to satisfy the commonality element of Rule 23 as membership in the class would turn on whether Hartford's delay was "reasonable" and require individualized factual inquiries.
