As expected, we were inundated with cases as the federal courts finished cleaning up their dockets before the September 30 Civil Justice Reform Act deadline. As a result, this week’s edition is especially meaty, with more than 30 cases addressing the full spectrum of ERISA issues.
This week’s big news was not any of those cases, however. Instead, it was yesterday’s Supreme Court oral argument in Anderson v. Intel Corp. Investment Policy Committee. As you may recall, this is a case in which participants in two of Intel’s ERISA-governed retirement plans contend, among other things, that the plan fiduciaries breached their duty of prudence by investing plan assets in poorly performing and costly hedge funds and private equity funds.
The issue before the court is whether, in pleading such claims, plaintiffs are required to allege a “meaningful benchmark” for comparison in order to support allegations of underperformance. Circuit courts have divided on this question. For example, in Anderson, the Ninth Circuit imposed such a requirement, while the Sixth Circuit (in Johnson v. Parker-Hannifin) has declined to do so.
Anderson’s counsel went first, arguing that courts should take a “holistic” approach to whether a plaintiff has stated a prudence claim, and should not carve up allegations and apply discrete tests such as a “meaningful benchmark” requirement.
He got broad pushback across the bench. Some justices suggested that where prudence is based on underperformance, some type of comparison must be conducted. Others wondered whether this particular case even depended on the application of a “meaningful benchmark” test, because Anderson’s argument was not based solely on underperformance – he had also argued that Intel made imprudent decisions and used a deficient process.
The justices also debated whether the true question was not about whether there should be a “meaningful benchmark” test, but how to apply that test. Much of the discussion was about how to compare “apples to apples,” with amusing exchanges like this: “JUSTICE THOMAS: So do you agree that you can’t compare apples and oranges? MR. WESSLER: Yes, but I think the question is, what is an apple and what is an orange?”
Intel’s counsel, and the solicitor general’s office, which supported Intel, received a much more friendly reception. The justices’ questions were mostly focused on the question of “if you win, what should we say?” The justices seemed concerned with whether they should simply affirm by saying that a “meaningful benchmark” test is appropriate, or whether they should go further and detail the contours of such a test. Intel’s counsel largely demurred. He noted that a bare affirmance would at least “bring the Sixth Circuit in line,” but that if the court wanted to do more, the Ninth Circuit’s approach was satisfactory.
Some type of clarification is probably likely, as Chief Justice Roberts stated that any “meaningful ruling” in the case would have to do “meaningful work” in order to give “some substance” to a test. Justice Kagan appeared to agree, suggesting that guidance was probably necessary because some courts applying the “meaningful benchmark” test had gone too far, for example, by requiring the exact same asset allocations when comparing funds.
In the end, it was a good day for plan administrators, but of course we will have to wait to see what the court decides, and how far it wants to go in that decision. Stay tuned!
Below is a summary of this past week’s notable ERISA decisions by subject matter and jurisdiction.
Arbitration
Fourth Circuit
Anthem Health Plans of Virginia v. AGS Health, No. 7:25-cv-00804, 2026 WL 2942234 (W.D. Va. Sept. 30, 2026) (Judge Robert S. Ballou). Recently here at Your ERISA Watch we have covered several cases rejecting attempts by healthcare providers to enforce awards issued in their favor against insurers pursuant to independent dispute resolution (IDR) proceedings under the No Surprises Act (NSA). (Indeed, just two weeks ago in our September 23, 2026 edition a Second Circuit decision on this issue was our case of the week.) In this case the tables have turned, and it is the insurer who is trying to obtain relief under the NSA. The plaintiffs are Anthem Health Plans of Virginia and Healthkeepers, and the defendants are two Schumacher Group entities, five affiliated emergency medicine provider groups, and AGS Health, their billing manager. Under the NSA, an out-of-network provider dissatisfied with an insurance payment may initiate negotiations and then IDR, in which a certified IDR entity (IDRE) makes a binding determination. That determination is not subject to judicial review except as provided by 9 U.S.C. § 10(a) of the Federal Arbitration Act (FAA). Plaintiffs alleged that defendants “submitted thousands of disputes that were plainly ineligible for the IDR process,” falsely attested to eligibility, flooded the process with negotiations and IDR initiations, and demanded inflated amounts. They claimed that “since 2024, nearly 60 percent of Defendants’ disputes that reached a determination were ineligible and Defendants have improperly secured millions of dollars in IDR awards[.]” The complaint pleaded ten counts, including under RICO and ERISA, and sought in the alternative vacatur of the IDR awards. Defendants moved to dismiss. The court first held that it lacked subject matter jurisdiction over every claim other than vacatur, including the RICO and ERISA claims. All of them rested on the same theory, i.e., that defendants obtained awards they should not have received, and so sought to invalidate or collaterally attack IDRE determinations. Because the NSA incorporates the FAA as the exclusive avenue for judicial review, a party “may not circumvent” those limits by repackaging an attack on an award as a RICO or ERISA claim. Plaintiffs argued that the NSA’s “no judicial review” provision “applies only to individual IDRE payment determinations and not to the fraudulent scheme alleged in this case,” contending that the NSA “addresses only payment determinations, not eligibility determinations.” The court disagreed for three reasons. First, whether an item or service is “qualified” is an eligibility question that an IDRE must answer before it can make a payment determination, so eligibility is part of the unreviewable determination. Second, plaintiffs’ reading would permit eligibility to be litigated in federal court after every IDR proceeding, “creating the very flood of lawsuits Congress intended to prevent.” Third, even if only payment determinations were shielded, the plaintiffs expressly sought “[r]elief from all improperly-obtained NSA IDR awards,” so a challenge to eligibility was necessarily a challenge to the resulting payment determination. On the remaining vacatur count, the court held that plaintiffs failed to state a claim under the FAA. The court assumed without deciding that fraud was plausibly alleged, although it noted that plaintiffs pleaded that over 40 percent of the disputes reaching a payment determination were eligible, and offered no facts suggesting bad faith as to the rest. However, plaintiffs’ alleged fraud was both discoverable and was discovered by plaintiffs, and thus they did not satisfy § 10(a)(1), which requires that “the fraud or corruption was…not discoverable upon the exercise of due diligence prior to the arbitration.” Plaintiffs had in fact objected as to the specific claims identified in the complaint, so they could not “credibly claim that the alleged fraud was not discoverable.” Vacatur under § 10(a)(4) (where an arbitrator “exceeds his powers”) also did not work. The court explained that IDREs are expressly authorized to determine eligibility under the NSA, so “an IDRE does not exceed its powers by performing a task that the regulations require and the statute presupposes.” The court thus granted defendants’ motions to dismiss, and because amendment would be futile, did so with prejudice.
Attorneys’ Fees
Third Circuit
Allied Painting & Decorating, Inc. v. International Painters & Allied Trades Industry Pension Fund, No. 21-13310 (RK) (TJB), 2026 WL 2983319 (D.N.J. Oct. 5, 2026) (Judge Robert Kirsch). Allied Painting & Decorating, Inc. contributed to the International Painters and Allied Trades Industry Pension Fund, a nationwide multiemployer plan, from 2001 to 2005. Allied withdrew during the 2005 plan year and incurred $427,195 in withdrawal liability, but the Fund did not send a demand letter until approximately twelve years later, in 2017. Allied objected that the Fund’s demand was barred by laches and by the requirement of 29 U.S.C. § 1399(b)(1) that a plan issue an assessment “[a]s soon as practicable.” At the time, many courts treated that requirement as coextensive with laches. The arbitrator found that the Fund had not acted “as soon as practicable” but ruled for it anyway because Allied had not shown prejudice from the delay. The district court granted Allied’s motion to vacate the award, and while the Fund’s appeal was pending, Allied moved for attorney’s fees, requesting $343,197 in fees and $8,862.49 in costs. In July of 2024, the Third Circuit affirmed, holding that § 1399(b)’s requirement “is not the same as a laches defense,” has no prejudice element, and therefore barred the Fund’s claim because no one had challenged the delay finding. (Your ERISA Watch reported on this decision in our July 17, 2024 edition.) On remand, Allied’s fee motion was reopened and the assigned magistrate judge issued a report and recommendation, recommending that the motion be denied. (We reported on this decision in our May 6, 2026 edition.) Allied objected, and in this order the court reviewed the report de novo. Allied first objected that the magistrate judge should have applied the five-factor test of Ursic v. Bethlehem Mines, which courts use for fee awards under the general fee provision of § 1132(g)(2), instead of Dorn’s Transportation, Inc. v. Teamsters Pension Trust Fund of Philadelphia & Vicinity. Allied argued that every circuit but the Third applies the same standard to both provisions. The court called the objection “self-defeating,” noting that Allied “curiously” did not dispute that Dorn’s sets the governing standard in this circuit, and that Allied’s real argument was that Dorn’s was wrong. Under Dorn’s, which governs fee awards to prevailing employers under § 1451(e), a court may award fees only if the plan’s assessment was “frivolous, unreasonable or without foundation.” Applying that rule, the magistrate’s report had found that the Fund could not have anticipated the Third Circuit’s “significant shift in the law,” because it was only that decision that made clear that “prejudice and, indeed the laches defense, have no place in the withdrawal liability calculus.” Allied’s objections did not challenge that finding, and the court independently agreed. Allied’s only alternative argument, developed in a one-paragraph reply brief without citation, was that the twelve-year delay was “patently prejudic[ial]” and the Fund’s claim “frivolous on its face.” The court said that this argument was arguably waived, but considered it anyway. It held that a finding of unreasonable delay does not make the assessment itself unreasonable, because § 1399(b) “sets no rigid timeframe” and, as the Third Circuit said in Allied, reflects “a deliberate legislative choice to afford some flexibility.” The court held in the alternative that under Ursic “the outcome here would not change,” and that Allied had forfeited any Ursic argument by failing to show “how the Ursic factors would support an award of fees in this case.” Under those factors, the Fund did not act in bad faith, and its position was no less meritorious than Allied’s merely because the law ultimately shifted. The court also saw “no beneficial deterrent effect in punishing a litigant for their failure to anticipate a significant shift in the law,” and held that the first three factors weighed strongly against fees regardless of the other two. Thus, the court adopted the magistrate judge’s report and recommendation and denied Allied’s motion for attorney’s fees.
Fifth Circuit
Krongold v. American Air Liquide Holdings, Inc., No. 4:23-cv-1971, 2026 WL 2925190 (S.D. Tex. Sept. 29, 2026) (Judge Keith P. Ellison). Martin Krongold sued American Air Liquide Holdings, Inc. under ERISA, alleging in Claim I that his projected pension benefit was improperly calculated because it omitted his car allowance, and in Claim II, under § 1132(a)(3), that Air Liquide miscalculated his benefits by refusing to consider his service with a former employer. The court granted Krongold summary judgment on Claim I in October 2024. A bench trial was held on Claim II, but even though the court found that Air Liquide made material misrepresentations, Krongold could not establish the remaining estoppel elements, and thus the court entered final judgment for Krongold on Claim I and for Air Liquide on Claim II. Krongold then sought $238,431.50 in fees, along with costs, prejudgment interest, and additional relief. The assigned magistrate judge recommended a reduced award of $33,105.24 (as we discussed in our August 12, 2026 edition), and Krongold objected. In this order the district court agreed with the magistrate that Krongold’s success was limited to Claim I, and that while his two claims were “interrelated” in arising from the same plan, the “burden of Plaintiff’s unsuccessful claim meaningfully outweighs his successful one.” It therefore upheld the magistrate judge’s lodestar calculation, limited to Claim I work before October 17, 2024. The court did sustain one objection, holding that because Krongold was awarded some fees, he was entitled to a partial award for time spent on the fee motion itself. However, the court rejected his request for additional costs, reasoning that § 1132(g)(1) is not a “blanket power to tax costs” and that costs like travel, postage, and courier fees fall outside 28 U.S.C. § 1920. It also denied prejudgment interest, since the unpaid benefits were never distributed and thus no use of funds required compensation. Furthermore, awarding interest as a response to Air Liquide’s misconduct “would turn the award into an improper penalty.” Finally, the court denied Krongold’s request for (1) a retroactive calculation, (2) “gross-ups” related to tax liability and Medicare premiums, and (3) statutory penalties, because none of these remedies had been awarded in the final judgment and thus could not be obtained on a fee motion.
Breach of Fiduciary Duty
Second Circuit
Bilodeau v. Verizon Communications, Inc., No. 25-cv-7057 (AS), 2026 WL 2936585 (S.D.N.Y. Sept. 30, 2026) (Judge Arun Subramanian). David Bilodeau and Elizabeth Dudley, participants in the Verizon Savings Plan for Management Employees, a defined contribution plan, challenged the plan’s use of forfeitures of unvested employer matching contributions. Section 4.04 of the plan provided that forfeitures “shall be applied” either “to reduce Company-Matching Contributions” or “to pay Plan expenses,” and § 10.11(d) provided that “[e]xpenses paid from the Trust shall be paid from forfeitures allocable under Section 4.04…and, to the extent not paid from such forfeitures, shall be paid from the Trust and allocated to some or all of the Funds on a pro rata basis.” The Verizon Employee Benefits Committee decided each year how to allocate any forfeitures. Plaintiffs alleged that from 2019 to 2023 the Committee used all or nearly all forfeitures to reduce Verizon’s matching obligations, while participants paid administrative expenses from their own accounts, including at least $23 annually in recordkeeping fees. In 2024, Verizon amended the plan to require forfeitures to offset contributions automatically, which plaintiffs did not challenge. Plaintiffs sued Verizon, its board of directors, and the Committee, asserting claims against the Committee for breach of the duties of loyalty and prudence and for engaging in prohibited transactions, and a failure to monitor claim against Verizon and the Board. Verizon moved to dismiss for failure to state a claim. The court noted that it was not the first to consider such a suit, that courts “come out different ways,” and that no circuit court had yet weighed in. “Suffice it to say, these are difficult issues, and the Court found the prior decisions on this issue to be very helpful in arriving at its conclusions.” The court first held that the Committee acted as a fiduciary and not a settlor because an employer wears its “fiduciary hat” when exercising discretion over plan assets and its settlor hat when deciding the “form or structure” of the plan. The court found that plaintiffs alleged a fiduciary function because they challenged how the plan was implemented, not how it was designed. The court acknowledged that this distinction might seem artificial, because Verizon could achieve the same result by amending the plan, but said it reflects “ERISA’s basic bargain”: employers choose the benefits, and participants are entitled to have the plan administered loyally and prudently. The court also clarified that plaintiffs were not claiming that using forfeitures to offset employer contributions was illegal per se, a theory the court agreed would be “difficult to justify,” but only that a discretionary choice must be made in accordance with fiduciary duties. As for plaintiffs’ specific claims, their loyalty claim survived. The court described Verizon’s choice as “a zero-sum game” in which the use of forfeitures to defray employer contributions benefits the company and their use for expenses benefits participants. Verizon argued that its conduct was authorized by the plan, but the court noted that fiduciary duties “trump[] the instructions of a plan document.” The legislative and regulatory history Verizon cited showed only that employers may structure plans to use forfeitures for contributions, not how fiduciaries must choose between options. Plaintiffs’ allegations that the Committee applied tens of millions of dollars in forfeitures to Verizon’s obligations while participants paid expenses, even though Verizon was “generating billions of dollars in annual profits,” were “more than enough.” The prudence claim also survived on two theories. The first was that the Committee reflexively applied forfeitures to Verizon’s benefit, without investigating whether doing so served participants. The second was that it let forfeitures roll over from year to year while participants paid expenses. The court further rejected Verizon’s argument that plaintiffs had not alleged an injury to the plan. It found that using forfeitures for contributions leaves the plan “stuck with the bill for expenses,” and it illustrated with a $1,000 plan how the same match and expenses left the plan $100 worse off. As for the failure to monitor claim, because it was derivative of the prior claims, it was allowed to proceed as well. However, plaintiffs’ prohibited transaction claim failed. The court ruled that “payment of benefits” is not a “transaction” under § 1106, which targets “commercial bargains” struck with plan insiders. The allocation of forfeitures involved no counterparty and only moved money within the plan, and “[i]f this counted as a ‘transaction,’ it’s hard to say what wouldn’t.” The court thus granted the motion to dismiss as to the prohibited transaction claims, which it dismissed with prejudice. However, the rest of plaintiffs’ claims survived, so the case will proceed.
Sixth Circuit
Gil v. Bridgestone Americas, Inc., No. 3:22-cv-00184, 2026 WL 2944487 (M.D. Tenn. Sept. 30, 2026) (Judge Eli Richardson). David Gil first worked for Bridgestone Retail Operations (BSRO) as a salaried manager trainee in 1996 and left in 2000 without a vested pension benefit. He returned in 2006 as an hourly employee when BSRO acquired his employer. The plan sponsor, Bridgestone Americas, Inc. (BSAM), “‘subsequently recognized later service with Bridgestone’ for vesting credit for employees, like Plaintiff, who were rehired as part of an acquisition.” In 2017, BSAM’s administrator, Willis Towers Watson (WTW), launched an online pension calculator, which Gil used repeatedly after acknowledging a disclaimer that its estimates might contain errors. The calculator apparently overestimated his benefit by crediting him with salaried service for years in which he was an hourly employee. When Gil initiated retirement in 2019, WTW realized the error and issued a retirement kit with the lower, correct benefit. The BSAM appeals board denied Gil’s appeal, and he kept working. Eventually, Gil sued both BSAM and BSRO in 2022. The court previously granted in part and denied in part defendants’ motion to dismiss, leaving a statutory penalties claim against BSAM under ERISA § 105 (Count I), and a breach of fiduciary duty claim against both defendants (Count II). (Your ERISA Watch covered this ruling in our August 28, 2024 edition.) The parties then cross-moved for summary judgment. On Count I, the court borrowed the one-year limitations period in Tenn. Code Ann. § 28-3-104(a)(1)(C), which applies to statutory penalties and which the parties agreed governed, while noting that federal law determines accrual, which occurs when the plaintiff “knows or has reason to know” of his injury. Defendants argued that Gil received a compliant pension benefit statement more than a year before he sued, alerting him to any prior miscalculation, and the court agreed. The 2019 retirement kit set out each component of Gil’s accrued benefit, the dollar amounts, and the employment and service data used to calculate them. Because the kit satisfied ERISA’s requirements from 2019 through the date of the complaint, any claim for noncompliance before the date of the kit was time-barred. BSAM was therefore entitled to summary judgment on Count I. On Count II, Gil’s theory that defendants breached fiduciary duties by failing to provide periodic benefit statements was unsuccessful because he cited no authority that such a failure independently supports a fiduciary claim, rather than only a claim for violation of Section 105. Gil’s second theory, that defendants ignored his inquiries, failed because his documented 2015 inquiry was in fact answered by defendants. On his remaining theory – that defendants misrepresented the amount of his pension through the calculator and failed to correct the overestimate once they learned of the error in July 2017 – the court skipped the questions of fiduciary status and materiality and resolved the claim on detrimental reliance. The only detriment Gil pleaded in his complaint was making an early election, but that occurred in 2016, before the 2017 and 2018 representations he challenged. Thus, there was no genuine dispute that Gil did not rely on the challenged representations in making the early election. The court therefore granted defendants’ motion for summary judgment and denied Gil’s.
Ninth Circuit
Foley v. Legacy Health, No. 3:25-cv-01041-AN, 2026 WL 2935341 (D. Or. Sept. 30, 2026) (Judge Adrienne Nelson). Four former employees of Legacy Health, a nonprofit health system in Oregon, participated in the company’s 403(b) and 401(a) retirement savings plans, both administered by the Legacy Health Retirement Committee. In this action they are challenging: (1) the 403(b) plan’s investment in the Lincoln Stable Value Separate Account (LSA GIC), a guaranteed investment contract that they alleged paid crediting rates 1.53 to 2.41 percentage points below the average of thirteen comparator stable value options from 2019 through 2023; (2) the plans’ investment in the TRP Growth Fund, which they alleged trailed its benchmark, the Russell 1000 Growth Index, and five peer funds; and (3) the use of forfeitures in the 401(a) plan to offset Legacy’s future contributions instead of plan expenses. The plan provided that remaining forfeitures “shall be applied to reduce future Employer contributions or to pay plan expenses,” and defendants allegedly applied more than $4.8 million to Legacy’s contributions from 2019 through 2023 and $0 to expenses, even though Legacy had enough cash to make its contributions. Their operative complaint asserts breach of the duty of prudence against the Committee, breach of the duty of loyalty against all defendants, and anti-inurement and failure to monitor claims against Legacy and its board of directors. Defendants moved to dismiss for failure to state a claim. Applying the Ninth Circuit’s decision in Anderson v. Intel Corp. Investment Policy Committee (argued before the Supreme Court yesterday, see above), the court explained that prudence is judged by the fiduciary’s methods and not its results. A plaintiff relying circumstantially on fund performance must compare it to “meaningful benchmarks,” since “[s]imply labeling funds as ‘comparable’ or ‘a peer’ is insufficient.” On the LSA GIC, plaintiffs pleaded no facts about defendants’ methods, having admitted that they lacked knowledge of the decision-making process. They argued that GICs are different from the mutual funds in Anderson. The court held that their process allegations (that the rate was reviewed semi-annually, that the market was “robust,” and that defendants had “considerable leverage”) were “too bare,” and that Anderson applies to GICs. The LSA GIC is a separate account GIC, riskier than a synthetic GIC and less risky than a general account GIC, according to plaintiffs’ own allegations. Plaintiffs alleged that two comparators were synthetic GICs and argued in their brief that a third was a separate account GIC, but defendants’ Form 5500s showed that each was a general account GIC. The court held that the Lincoln Financial Fixed Account was not a benchmark merely because Lincoln offered both. As for the TRP Growth Fund, that was “a closer question,” since plaintiffs alleged consistent underperformance against the benchmark index assigned to it by the investment policy. But the cases they cited involved underperformance combined with something more, such as proprietary funds, excessive fees, or a failure to follow the policy’s review requirements. The court held that underperformance alone does not suffice. Plaintiffs did not allege that defendants owned the fund, violated a policy requirement, or paid excessive fees, and they pleaded nothing about the five peer funds beyond names and returns. Sharing a benchmark “does not equate to sharing aims, risks, and potential rewards.” On forfeitures, the court observed that the plan expressly allowed either use and that defendants followed it. It noted that “reasonable courts have indeed disagreed on this issue, and it is not obvious that either view is necessarily correct,” and acknowledged that a fiduciary can breach its duties by acting out of self-interest even when the plan permits the choice. But the allegations here were “too sparse.” Many of plaintiffs’ allegations were conclusory, and only three were sufficiently specific: that Legacy could afford its contributions, that defendants did not investigate whether it could if forfeitures paid expenses, and that they consulted no independent decision maker. “Stripped of conclusory allegations,” the court said, plaintiffs’ theory amounted to a categorical rule that forfeitures must pay expenses whenever the company can afford to make contributions, which would create a benefit the plan does not provide. The anti-inurement claim failed because reallocating forfeitures within a plan does not violate § 1103(c)(1), and plaintiffs did not allege that any forfeitures left the plan or were used for anything other than participant benefits. Finally, the failure to monitor claim, being derivative of the prudence claims, fell with them. The court thus granted defendants’ motion and dismissed the case, although it gave plaintiffs leave to amend.
Class Actions
Ninth Circuit
Schuster v. Swinerton Inc., No. 3:24-cv-04970-JSC, 2026 WL 2959699 (N.D. Cal. Oct. 1, 2026) (Judge Jacqueline Scott Corley). Michael Schuster and Juan Del Barco brought this breach of fiduciary duty action on behalf of a putative class of participants in Swinerton Inc.’s retirement savings plan. Plaintiffs asserted, among other things, that the plan’s recordkeeping and administrative fees were excessive. The parties notified the court in March of 2026 that they had reached a settlement, and plaintiffs moved for preliminary approval of a class action settlement. After a hearing, the court identified some issues with the proposal and ordered the parties to try again. (We covered this ruling in our August 19, 2026 edition.) The parties filed supplemental submissions, and in this order the court approved the motion. Under the settlement agreement, defendants will pay $497,500, from which the court was told that up to $50,000 in notice and administration costs, up to $25,000 in litigation expenses, attorneys’ fees of 25% of the fund ($124,375), the costs of an independent fiduciary, taxes, and service awards of up to $5,000 per class representative may be deducted. The balance will be allocated pro rata based on each class member’s plan account balance and the duration of those balances during the class period. Class members who do not exclude themselves release a broad range of claims relating to the selection and monitoring of plan fiduciaries and service providers and the fees and services at issue, though not claims to the value of their vested account balances. Because the class is a Rule 23(b)(1) class, members may object but may not opt out. The court preliminarily certified the class under Rule 23(a) and Rule 23(b)(1)(A). Approximately 6,000 participants made the class sufficiently numerous, and commonality was satisfied because the questions of whether the plan’s recordkeeping fees were excessive, whether defendants breached their fiduciary duties, and whether the plan suffered losses were common to all members. Typicality was met because plaintiffs challenged a single course of conduct, the management of the plan, and adequacy was met because there was no evidence of conflicts. The court noted that “[m]ost ERISA class action cases are certified under Rule 23(b)(1),” and held that individual suits by roughly 6,000 participants would risk “incompatible standards of conduct” for defendants, so it did not address Rule 23(b)(1)(B). Turning to the fairness of the settlement, the court noted that it followed a full-day mediation with an experienced ERISA mediator. The only preferential treatment was the requested service awards, on which the court deferred ruling until final approval. On the range of possible approval, plaintiffs estimated that the $497,500 fund represented 22.1% of total estimated losses, which they argued was consistent with or better than recoveries in comparable ERISA class actions. Based on a model of the pro rata distribution, the settlement administrator estimated that current participants would receive an average of $47.40 and a median of $16.17, ranging from $0.01 to $718.02, while former participants would receive an average of $80.34 and a median of $57.64, ranging from $25.02 to $434.19. The court had initially raised concerns, including about the release language and the notice, but found that plaintiffs’ supplemental submissions resolved them. As for fees, class counsel’s current lodestar of $150,190, with an estimated lodestar of $177,190 through final approval, meant that a 25% award would represent a negative multiplier. The court required a fee motion with declarations and detailed billing records so it could determine the appropriate lodestar and so class members could object. The court thus granted preliminary approval of the settlement and provisionally certified a settlement class of all persons who participated in the plan during the class period, with limited exceptions. A final approval hearing will be held in February of 2027.
Disability Benefit Claims
Eighth Circuit
Farley v. Hartford Life & Accident Ins. Co., No. 4:24-cv-00894-SEP, 2026 WL 2971836 (E.D. Mo. Sept. 30, 2026) (Judge Sarah E. Pitlyk). Krystal Farley, a nurse, last worked in 2020, when she was hospitalized for diabetic ketoacidosis and developed acute respiratory distress, pneumonia, and respiratory failure, ultimately losing part of her left lung. She was covered by her employer’s long-term disability plan, which was insured and administered by Hartford Life and Accident Insurance Company. The plan defined disability under an “Own Occupation” standard for the first 24 months and an “Any Occupation” standard thereafter, the latter requiring that the claimant be unable to perform any occupation “for which You are qualified by education, training or experience.” Hartford found Farley disabled through the end of the Own Occupation period but denied benefits under the Any Occupation standard. The denial relied on a physician reviewer, Dr. Rafid Fadul, who found Farley capable of sitting without restriction but of standing and walking only occasionally, for up to twenty minutes at a time and up to one hour per day, and on an employability analysis identifying four sedentary occupations that she could perform with “minimum training.” Farley appealed, but Hartford upheld its decision, although it did so after the regulatory deadline. (Hartford later argued that it did not receive Farley’s appeal in a timely fashion because Farley had mailed it to the wrong address and her counsel’s fax listed an incorrect claim number.) Farley thus brought this action, and the parties filed cross-motions for judgment. The court first held that Hartford’s decision would be reviewed de novo despite the plan’s grant of discretion. The court acknowledged that the Eighth Circuit had held (in McIntyre v. Reliance Standard Life Ins. Co.) that an administrator’s delay is “not a trigger for de novo review” but only a factor in abuse of discretion review. However, that ruling interpreted the 2002 amendments to the regulation; the 2016 amendments to the regulations require disability plans to “strictly adhere” to claims procedures. If they do not, the claim “is deemed denied on review without the exercise of discretion by an appropriate fiduciary,” subject only to a de minimis exception. The court found that the record documented Hartford’s receipt of the appeal by fax, that Farley had satisfied Hartford’s own instructions for appeals, and that Hartford’s letters confirmed receipt on that date. Even assuming Hartford’s lateness was de minimis, it failed the remaining prongs because Farley was likely prejudiced by the delay and Hartford identified no good cause, since its “attempts to blame Plaintiff for its own mistake cut against a finding of good cause.” The claim was therefore deemed denied when Hartford’s deadline expired, and the court did not consider Hartford’s ultimate denial or the employability analysis accompanying it. Reviewing the original denial de novo, the court overturned it for two reasons. First, the employability analysis relied on occupations Farley could perform with “minimum training,” but the plan’s Any Occupation definition imposed no retraining requirement, and the analysis never explained the extent of the training that would be needed. Second, Hartford’s conclusion that Farley could perform sedentary work ignored the limitations found by its own reviewer. Sedentary jobs require walking and standing only “occasionally,” meaning up to one third of an eight-hour day, or about two hours and forty minutes. Even reading Dr. Fadul’s report in Hartford’s favor as permitting one hour of standing and one hour of walking, Farley’s limit of two hours fell short. The court thus granted Farley’s motion for summary judgment and denied Hartford’s cross-motion. The court remanded, stating that if Hartford “cannot identify any occupation that Plaintiff may perform, Plaintiff is entitled to disability benefits under the Plan.”
Ninth Circuit
Whitlock v. Provident Life & Accident Ins. Co., No. 25-cv-0964-AGS-VET, 2026 WL 2966232 (S.D. Cal. Sept. 30, 2026) (Judge Andrew G. Schopler). While working for Lockton Companies, Suzanne Whitlock elected to participate in a voluntary “top-up” disability program that Lockton offered alongside its broader welfare benefit plan. The program was funded through individual policies issued by Provident Life and Accident Insurance Company and its parent, Unum Group. Premiums were deducted from employees’ paychecks, and after Whitlock left Lockton she kept the coverage, paid the premiums herself, and retained the discount Lockton had negotiated. In 2021, she was diagnosed with generalized anxiety disorder and major depressive disorder, and her psychiatrist recommended that she work no more than 40 hours per week, later lowering that to 32. She reduced her workload and took a substantial pay cut at her then-employer, HUB, and submitted a disability claim to Provident, which denied her claim and her subsequent appeal. Whitlock then brought this action (initially through counsel but transitioning to pro se), and the case proceeded to cross-motions for judgment. The court first held that ERISA governed the policy. The court found that Lockton had negotiated a discounted rate representing a 30% reduction from market premiums, along with portability and payroll deduction, and it received a single bill and remitted a lump sum to Provident. Whitlock argued that Lockton merely permitted insurer communications, facilitated payroll deductions, and transmitted enrollment data, but the court observed that such operational functions “would support ERISA coverage, not undercut it,” and that Lockton’s actions were more than “clerical or procedural duties.” The court also noted that Lockton had filed mandated ERISA disclosures, such as a Form 5500 and a summary annual report. Thus, there was no “post hoc ‘ERISA-IF-ICATION,’” as Whitlock asserted. The court next held that the plan did not qualify for the safe harbor in 29 C.F.R. § 2510.3-1(j), because the plan failed the endorsement and consideration prongs of the relevant four-part test. The plan failed the endorsement prong because Lockton negotiated reduced rates and offered the program with its broader welfare plan, and it failed the consideration prong because Lockton’s Form 5500 identified Lockton as receiving commissions and fees for the plan. As a result, because ERISA applied, Whitlock’s state law claims were preempted and dismissed. Next, Whitlock argued that Provident evaluated her under the “Total Disability” and “Residual Disability” definitions rather than the policy’s “Partial Disability” standard. The court agreed that the initial denial letter used the wrong terms but found the error immaterial. The court found that Provident’s reviewing physicians never applied policy language, the appeal decision cited the correct partial disability provisions, and under Ninth Circuit authority the only remedy for flagrant procedural violations is de novo review, which the court was applying anyway. On the merits, as mentioned, the court applied de novo review, presuming that the long-term disability plan, which contained no grant of discretion, was severable from Lockton’s welfare plan, which did. The court agreed that Whitlock showed a salary reduction of roughly 32.5%, satisfying the policy’s 20% loss of earnings requirement, but offered “virtually no evidence” on the remaining elements, and instead “fixated” on whether ERISA applied. Although Whitlock did not satisfy her burden, the court examined the record out of solicitation for her pro se status. It found that Whitlock’s treating psychiatrist rated her risk level “low” or “minimal,” noted that her symptoms improved after she left HUB, and attributed her condition to her work environment and “situational stressors,” while a reviewing psychiatrist found that the records “do not document severe and persistent symptoms” and that she was working 32 to 40 hours a week growing her own company. Because Whitlock had maintained and then increased her workload at her own company, she failed to show that she could not perform the material and substantial acts of her usual occupation. The court thus granted Provident’s motion for judgment and denied Whitlock’s.
Eleventh Circuit
Edwards v. Reliance Standard Life Ins. Co., No. 2:25-cv-00558-MHH, 2026 WL 2963512 (N.D. Ala. Sept. 30, 2026) (Judge Madeline Hughes Haikala). Plaintiff Lucille Edwards worked as a clinical nurse at Alameda Health System in California and was covered by its employee long-term disability benefit plan, which was insured by Reliance Standard Life Insurance Company. Edwards submitted a claim under the plan to Reliance, alleging disability due to anxiety and depression. Her therapist’s notes reflected severely impaired attention, concentration, and memory, and she attended counseling about twice per month during the 180-day elimination period. Edwards fractured her foot after the elimination period ended. Edwards filed a claim for benefits, but Reliance denied it after a file review by a licensed clinical social worker concluded that the evidence did not establish a functional impairment. On appeal, Reliance intended to conduct an in-person examination, but learned that Edwards had moved to Alabama, so commissioned a file review from Dr. Brandon Erdos instead. Reliance then upheld the denial. This action followed in which the parties cross-moved for summary judgment. The court applied the Eleventh Circuit’s idiosyncratic six-step ERISA benefits framework, beginning with whether Reliance’s decision was “de novo wrong.” At the outset, the court set the foot fracture aside because it post-dated the elimination period, leaving the psychiatric claim as the only basis for benefits. On that claim, the court found that the record lacked objective evidence of functional limitation. Dr. Erdos found no clinical findings supporting disabling severity and observed that Edwards’s treatment frequency was “not typical or consistent with” impairing symptoms. The treatment notes described a patient who was alert and oriented, with no suicidal or homicidal ideation, and the record contained no medication during the elimination period and no restrictions imposed by a treating provider. The court stated that “[t]he limited number of treatment sessions suggests a non-severe impairment,” and, as for the reported cognitive deficits, “[n]europsychological testing could have assisted in determining whether Ms. Edwards’s conditions were causing functional impairment. No such testing appears in the record.” The court explained that a plan administrator need not give greater weight to a treating provider’s opinion, particularly where the opinion rests on subjective complaints, and stated that “where the plan puts the burden on the claimant to prove that she is disabled, it is implicit in the requirement of proof that the evidence be objective.” The court rejected Edwards’s arguments regarding Reliance’s conflict of interest and its use of a file review. The court acknowledged that a structural conflict of interest is a factor to be weighed, but Edwards offered no evidence that Reliance’s dual role as insurer and administrator improperly influenced its decision. Reliance’s use of a file review rather than an in-person examination “does not, standing alone, render its decision incorrect.” As a result, because Reliance’s decision was not “de novo wrong,” the court ended its inquiry at step one and granted Reliance’s motion while denying Edwards’s.
Krambeck v. Unum Life Ins. Co. of Am., No. 8:24-cv-2102-TPB-NHA, 2026 WL 2935928 (M.D. Fla. Sept. 30, 2026) (Judge Tom Barber). Briana Krambeck, a Major Sales Assistant at a Costco store in Nebraska, became ill with COVID-19 in May 2020 and took medical leave. She later reported shortness of breath and dysphonia (hoarseness and difficulty speaking), among other symptoms. Unum Life Insurance Company of America, the claims administrator for Costco’s long-term disability plan, approved benefits in January 2021 based on her inability to perform her own job. After nine months, the policy required that she be “unable to perform the duties of any gainful occupation for which [the employee is] reasonably fitted by education, training or experience.” It was undisputed that an inability to speak for more than 30 minutes a day would meet that standard. In September 2021, Krambeck’s treating physician, Dr. Angela Law, told Unum that Krambeck could do full-time sedentary work but could speak for only 30 minutes a day, which ruled out a telephone job. Unum’s in-house physician spoke with Dr. Law and sent her a letter stating that she had agreed Krambeck could work in a sedentary occupation requiring speaking “occasionally,” meaning up to 2.5 hours a day, and inviting revisions. Dr. Law did not respond, and Unum terminated benefits. Two weeks later, Dr. Law sent a revised version of her response changing her answer on sedentary work from “Yes” to “No,” without mentioning the call or the letter. Unum reviewed the file again and, relying on two more physician reviews, again denied her claim and her appeal. Krambeck thus brought this action seeking reinstatement of benefits, while Unum counterclaimed to recover benefits already paid because she received Social Security disability benefits for the same condition. Both sides moved for summary judgment. The court applied the Eleventh Circuit’s idiosyncratic six-step framework for ERISA benefit cases, which the court noted was “likely unnecessarily complex.” The court questioned whether ordinary summary judgment principles could be set aside at the first step, which asks whether a decision was “de novo wrong.” The court determined that the conflicting opinions of the various doctors, together with credibility questions about the call and the correspondence, “would ordinarily present classic issues of fact for trial.” Because neither side had consented to a bench trial on the papers, the court, “in an abundance of caution,” declined to weigh the evidence and denied both motions on the benefits claim. The court then discussed the operative standard of review, noting that the policy expressly gave Unum discretionary authority. However, Krambeck argued that Washington law governed and barred discretionary clauses in disability policies. Unum argued that the Washington regulation took effect in 2009, after the policy’s 2001 effective date, and could not apply retroactively. The court found that the policy contained a 2020 amendment stating that “[t]he entire policy is replaced by the policy attached to this amendment,” effective January 1, 2020, so applying the regulation was not retroactive. As a result, Unum lacked discretion and review would be de novo. Finally, on Unum’s counterclaim, the court explained that Unum could seek only equitable relief under § 502(a)(3), meaning relief aimed at a specific fund in the defendant’s possession and not her general assets. Krambeck’s declaration stated that the benefits she received from Unum and the Social Security Administration, more than $24,000 retroactive to 2021, had been spent and were not traceable to identifiable assets. Unum offered no contrary evidence or argument, and thus its claim failed. Thus, while Krambeck prevailed on Unum’s counterclaim, both sides’ motions were denied in every other respect. The court declared it would schedule a bench trial by separate notice unless the parties filed a joint submission agreeing to an alternative procedure.
Discovery
Fourth Circuit
Craig M. v. Blue Cross & Blue Shield of N. Carolina, No. 1:25-CV-588, 2026 WL 2957939 (M.D.N.C. Oct. 1, 2026) (Magistrate Judge JoAnna Gibson McFadden). Craig M., suing on behalf of himself and his minor child, S.M., alleged that Blue Cross and Blue Shield of North Carolina (BCBS) wrongly denied coverage for S.M.’s treatment, asserting a claim for benefits under ERISA § 502(a)(1)(B) and a Mental Health Parity and Addiction Equity Act claim under § 502(a)(3). BCBS served written discovery on plaintiff, after which it moved to compel fuller responses and sought sanctions. Meanwhile, plaintiff asked to seal portions of BCBS’s briefing and more than ten exhibits. The first dispute turned on the parties’ agreement. In their joint Rule 26(f) report, they agreed that discovery on the ERISA claim was “limited to the full and complete pre-litigation appeal record,” but that either side could move by February 19, 2026, for additional discovery on the amount at issue or on exhaustion of administrative remedies. The court adopted that schedule. The deadline passed without a motion, BCBS served discovery the next day, Craig M. answered by pointing to the administrative record, and BCBS did not move to compel until June 29, 2026. The court held that BCBS’s motion to compel exhaustion discovery was “four months too late,” and denied it as to the exhaustion-related interrogatories and document requests, declining also to deem related requests for admission admitted. The damages discovery was treated differently. Because Craig M. had conceded that his out-of-pocket expenses were discoverable and had produced some information, the dispute concerned the sufficiency of his responses and not the need for discovery, so the deadline did not apply. BCBS argued that plaintiff’s responses were irreconcilable because his “responses show that the provider billed him $171,513 but he paid $273,189.33 or possibly $151,088.35.” The court rejected Craig M.’s belated objection that the requests sought “extra-record discovery” and ordered further responses that “clearly presents the precise information that BCBS requests” and explains any inconsistencies. The Parity Act claim produced a separate ruling. In response to interrogatories asking for the facts supporting his claims that a plan term and BCBS’s denial violated the Parity Act, Craig M. referred BCBS to his complaint and appeal letters, citing Rule 33(d). The court called him “mistaken,” as a complaint is not a business record under that rule and was not responsive. It ordered complete narrative responses. Finally, the court denied the motion to seal. Plaintiff cited “no law on the public’s right of access to the courts, the sealing standards, or the propriety of sealing the requested information,” and did not comply with local rules. The stipulated protective order did not relieve him of the burden to show that sealing was necessary. Furthermore, his descriptions of the exhibits were “vague and inaccurate,” as they did not reveal his family’s financial information or his child’s medical history. The court directed BCBS to file the exhibits at issue publicly, but with the family members’ full names redacted to their initials in accordance with the pseudonyms plaintiff were using.
Eighth Circuit
Gibson v. Unum Life Ins. Co. of Am., No. 25-2711 (JWB/JFD), 2026 WL 2983259 (D. Minn. Oct. 5, 2026) (Judge Jerry W. Blackwell). Tyronne Gibson sued Unum Life Insurance Company of America after it denied his claim for ERISA-governed long-term disability benefits. Count I seeks benefits under ERISA § 502(a)(1)(B), and Count II seeks equitable relief under § 502(a)(3) for alleged breaches of fiduciary duty in Unum’s handling of the claim. The dispute in this order concerned only Count II. Gibson filed a motion seeking discovery outside the administrative record about Unum’s claims-handling process, including a conversation between his treating physician and an Unum physician reviewer, whether the reviewer accurately reported it, and why Unum kept relying on the reviewer after Gibson raised concerns. Unum argued that Count II was “not meaningfully distinct from the benefits claim” and that, because benefits would be reviewed de novo, any challenge to claims administration was irrelevant. In January of this year the assigned magistrate judge granted Gibson’s motion, concluding that his separately pleaded fiduciary duty theory could involve facts outside the administrative record, while expressly declining to decide the merits or viability of Count II. (Your ERISA Watch reported on this ruling in our January 28, 2026 edition.) Unum objected and this order was the result. The court found support for the magistrate’s order in two Eighth Circuit decisions. In Silva v. Metropolitan Life Ins. Co., the court held that plaintiffs are not required to elect between § 502(a)(1)(B) and § 502(a)(3) remedies at the pleading stage. Jones v. Aetna Life Ins. Co. was “even more directly applicable.” There, a plaintiff pleaded a disability benefits claim and a fiduciary duty claim based on the claims-handling process, and the Eighth Circuit held that the counts rested on different theories even though they sought functionally identical relief, because § 502(a)(3) liability flowed from the allegedly improper process and not from the denial itself. The court further held that Unum’s reliance on de novo review did not change the result. The parties agreed that discovery on the benefits claim is limited to the administrative record, and the court accepted that process deficiencies do not determine whether Gibson was disabled. But the magistrate’s order did not expand the record on Count I, and whether process evidence is material to disability is a different question from whether it is relevant to a fiduciary theory. Unum’s argument under 29 C.F.R. § 2560.503-1(l)(2), that the remedy for a failure to provide a full and fair review is de novo review “misses the mark” because Count II also alleged factual misrepresentations about the treating physician conversation. The court deferred to the magistrate judge’s view that it was too soon to say the administrative record held everything relevant to Count II. The court closed by stressing the limits of its ruling. It would not comment on whether Count II would succeed or whether any recovery would duplicate relief under Count I, and Silva left open whether a plaintiff may later be required to elect a theory “once full discovery has been conducted.” “Affirmance does not authorize open-ended discovery,” and Rule 26’s relevance and proportionality requirements still applied. Finally, the court denied Gibson’s request for fees incurred in responding to the objections, because Unum’s objections raised “nonfrivolous questions” about the scope of discovery and the relationship between the two provisions.
Payne v. Hormel Foods Corp., No. 24-cv-545 (SRN/SGE), 2026 WL 2948833 (D. Minn. Oct. 1, 2026) (Magistrate Judge Shannon G. Elkins). Scott Payne alleges in this putative class action that Hormel Foods Corp. and its board of directors imprudently administered two defined contribution plans in breach of their fiduciary duties under ERISA. Previously, the court denied defendants’ motion to dismiss (as we reported in our September 25, 2024 edition), and the case proceeded to discovery. Before the court here was a dispute over expert disclosure on plaintiffs’ class certification motion. Over Payne’s objection that “there is no rule or procedure that authorizes separate experts for class certification proceedings,” the court’s pretrial scheduling order (PTSO) set separate deadlines for class certification and merits experts. As amended, the PTSO allowed a party to designate the same expert for both stages, but required Payne to disclose class certification experts by November 3, 2025, and merits experts by June 1, 2026, with class certification briefing in between. Payne disclosed no class certification expert, and his April 2026 motion cited none. He then served the merits report of Christopher Tobe on June 1 and, on June 5, the day his class certification reply was due, served a “supplemental” Tobe report with hundreds of changes and filed it with a reply that relied heavily on it. Hormel moved to exclude the report or, alternatively, to file a sur-reply. The court evaluated whether Payne’s conduct violated the PTSO and whether exclusion was warranted under Federal Rules of Civil Procedure 16(f)(1)(C) and 37(c)(1). The court ruled that there was “no legitimate debate” that Payne violated the PTSO. His argument that the PTSO “places no limit on how a disclosed expert may be used,” so that he could disclose experts for any purpose by the merits deadline, was “a nonsensical argument that ignores the disclosure provisions in the PTSO and renders the class certification expert deadlines irrelevant.” Tobe’s opinions supported the class certification motion, and thus he was a class certification expert whatever the substance of his opinions. The court further found clear prejudice. Hormel could not depose Tobe, offer a rebuttal expert, address his opinions in its opposition, or bring a Daubert challenge, which was “exactly the kind of surprise that scheduling orders are designed to prevent.” A sur-reply would not cure the prejudice and further discovery would delay a case already more than two years old and undo the bifurcated schedule. Because Payne had opposed bifurcation from the outset, the court was also “hard-pressed to conclude that Mr. Payne’s conduct was not willful.” The court thus granted Hormel’s motion to exclude Tobe’s report in connection with Payne’s motion for class certification.
Ralston v. Lesser, No. 4:25-cv-01325-SEP, 2026 WL 2936281 (E.D. Mo. Sept. 30, 2026) (Judge Sarah E. Pitlyk). Heidi Ralston, a participant in the ARCO Holdings, Inc. employee stock ownership plan (ESOP), alleged that in a 2019 transaction Aegis Trust Company, LLC and Robert E. Lesser, the ESOP’s trustee, caused the ESOP to buy 100 percent of the voting stock of ARCO National Holdings, Inc. from the selling shareholder defendants for more than fair market value. She left her employment in 2022 and cashed out her shares in 2023. Her putative class action seeks the difference between the price the plan paid and fair market value. Four similar suits against ARCO entities were consolidated for pretrial purposes into this case. The shareholder and director defendants moved under Rule 12(b)(1) to dismiss Counts II and III for lack of Article III standing, attaching Ralston’s account statements to show that the per share price rose from $248 in 2019 to $331.24 in 2022, so that she enjoyed a net gain and suffered no financial injury. Because the statements were not referenced in the amended complaint, the court treated the motion as a factual attack. Ralston moved for limited jurisdictional discovery into whether the ESOP paid fair market value, seeking the transaction binder, the trustee’s valuation advisor’s report, any other advisors’ reports the trustee reviewed, and the fiduciary committee’s notes. The court explained that Rule 12(b)(1) motions, unlike Rule 12(b)(6) motions, “often raise factual issues that require the Court to look outside the pleadings,” and that “where issues arise as to jurisdiction or venue, discovery is available to ascertain the facts bearing on such issues.” Defendants argued that “no amount of discovery” could show injury because the share price rose. The court said this “ignores the crux” of Ralston’s argument, which was not that the price fell but that she received reduced appreciation because the plan overpaid in 2019. The court also rejected defendants’ claim that her request rested on speculation. She had identified specific reasons the documents could support her theory, including that the ESOP received no discount for lack of control or marketability, that synthetic equity granted to the sellers diluted participants’ shares, that the financial projections and comparable companies used in the valuation were unreasonable, and that the trustee did not challenge the valuation analysis. Requiring more would be unreasonable because “ERISA plaintiffs generally lack the inside information necessary to make out their claims in detail unless and until discovery commences.” The court found that Ralston’s request for discovery was “narrowly tailored to her needs and clearly defined,” and defendants had not argued that it was burdensome. As a result, Ralston’s motion for leave to conduct jurisdictional discovery was granted. Because the parties agreed that the other pending motions were “inextricably intertwined” with the discovery issue, and discovery might lead to an amended complaint, the court denied those motions without prejudice.
ERISA Preemption
Second Circuit
Fein v. Zottola, No. 25-CV-6889 (KMK), 2026 WL 2925966 (S.D.N.Y. Sept. 29, 2026) (Judge Kenneth M. Karas). Seth Fein sued his sister, her husband, and their two sons regarding the disposition of his mother Sandra Fein’s TIAA-CREF retirement account. After Sandra’s death in 2023, Fein alleged he learned that beginning in 2009 his sister had altered the beneficiary designations on Sandra’s account from an equal split between the siblings to an 80/20 division in her favor, and later to a five-way split. He alleged that his sister, who held Sandra’s power of attorney, sometimes acted on the account “pretending that she was” Sandra, and asserted state law claims for conversion, fraud, breach of fiduciary duty, identity theft, and unjust enrichment. Defendants moved to dismiss under Rule 12(b)(1), arguing that no federal question was presented; Fein countered that the claims arose under federal law because the account was ERISA-governed. Applying the Supreme Court’s two-part test from Aetna Health, Inc. v. Davila, the court held that Fein’s claims were not completely preempted by ERISA § 502(a)(1)(B) and thus it did not have jurisdiction. On the first prong, although Fein, as a beneficiary, was the type of party who could sue under § 502(a)(1)(B), his claims were not colorable claims for benefits, because the complaint targeted a fellow beneficiary’s alleged misconduct rather than the plan administrator’s benefit determinations. As the court put it, “[w]hile the Court in no way intends to undermine the seriousness of identity theft, such conduct does not imply the propriety of the plan administrator’s benefit determinations.” Defendants were also not proper § 502(a)(1)(B) defendants because the complaint did not allege that they were plan administrators, trustees, or otherwise had “total control over the plan claims process.” On the second prong, the court concluded that defendants’ duty not to take another’s property through fraud, conversion, or unjust enrichment was an independent legal duty, not “inextricably intertwined” with interpretation of plan coverage and benefits, and that the case concerned the “amount of payment” rather than the “right to payment.” “Whether Ms. Zottola engaged in deception when interacting with TIAA-CREF is not ‘inextricably intertwined with the interpretation of Plan coverage and benefits,’ rather, it has nothing to do with the terms of the Plan’s coverage.” As a result, because the claims did not arise under federal law, the court lacked subject matter jurisdiction and granted defendants’ motion to dismiss.
Millman v. Ethos Risk Services, LLC, No. 24-CV-4370 (KMK), 2026 WL 2925891 (S.D.N.Y. Sept. 29, 2026) (Judge Kenneth M. Karas). Jeffrey Millman suffered a cerebrospinal fluid leak in 2019 that left him with intracranial hypertension and chronic headaches and unable to work at BNY Mellon. He received long-term disability benefits under a BNY Mellon plan insured by The Lincoln National Life Insurance Company. In 2023, a new Lincoln claim specialist decided that an independent medical exam and surveillance were needed. Lincoln hired Emperion MCN f/k/a Genex Services (ECN) to arrange the exam, and ECN retained Dr. James A. Charles, whose first opinion concluded that Millman could not work an eight-hour day and that his complaints were substantiated. Lincoln also had Ethos Risk Services, LLC, a licensed private investigator, surveil Millman at his son’s Little League game, producing video footage and a report noting that he “was observed walking with a limp.” After ECN sent Dr. Charles the Ethos report and footage, he issued a second opinion reversing course and stating that Millman “can work in any capacity.” Lincoln denied benefits based on that second opinion. Millman alleged that his expert found the video had been selectively redacted, and that Lincoln’s claimed transmission of the second opinion to his doctors went to an outdated address. On appeal, a different Lincoln doctor found Millman disabled and his benefits were reinstated. Millman and his wife alleged severe emotional distress, a stay at the Mayo Clinic, lost earnings, and $31,000 in interest on loans taken to replace his lost income. The Millmans first sued Ethos, and then amended their complaint three times, adding Dr. Charles, Lincoln, and ECN as defendants. The operative complaint alleges numerous claims under state law. All four defendants moved to dismiss for failure to state a claim, but only Lincoln argued ERISA preemption, which the court treated as “a threshold question.” The court stated that complete preemption, a jurisdictional concept, was “irrelevant” because the Millmans had invoked diversity jurisdiction, leaving only the question of express preemption under ERISA § 514(a). The court held that all of plaintiffs’ claims were preempted because they impermissibly “related to” the benefit plan. First, the defamation claims rested on the doctored video, the Ethos reports, and Dr. Charles’s second opinion, all of which were used to terminate benefits and none of which was alleged to have been communicated to anyone other than Lincoln or those it retained to investigate the claim. The court reasoned that the claims were thus an “alternative remedy” for the benefits termination, and that state common law claims are preempted even when they seek remedies beyond the plan’s terms because ERISA provides the only permissible recourse. Pointing out that Millman “availed himself of the appeals procedure and successfully got his benefits reinstated,” the court concluded that “[t]o permit the Plaintiffs to bring state law claims premised, in function if not in form, on the wrongful benefits denial would be to impermissibly interfere with the administrative process for appeal and remedies contemplated by ERISA’s regulatory scheme.” The court found that the cost of analyzing the video, appeal legal fees, the wife’s lost earnings, loan interest, and increased pain, were still “damages for the consequences of the termination decision.” The remaining claims fared no better. The tort claims against Ethos and Dr. Charles concerned conduct “inextricably intertwined with the benefits analysis process,” because deciding whether it was wrongful would require the court to examine the claims process. The aiding and abetting claims, which targeted the same video, report, and exam, concerned “the conduct of a fiduciary and third parties in relation to the plan.” The intentional and negligent infliction of emotional distress claims were likewise premised on the improper investigation and processing of the disability claim. Finally, as for plaintiffs’ claim based on New York General Business Law § 74, the court noted that no case had addressed whether such a claim is preempted, but held that it was because it was premised on the denial of benefits. Because only Lincoln raised preemption, the court dismissed the claims against the remaining defendants sua sponte, concluding that because all of plaintiffs’ claims rested on the same facts concerning the processing of Millman’s claim, ERISA’s preemptive effect applied equally to all defendants. The court allowed plaintiffs to amend their complaint, although it warned that they would have to “allege facts pointing to wrongful conduct by the Defendants arising outside of the context of the disability benefits determination.”
Life Insurance & AD&D Benefit Claims
Sixth Circuit
Wright v. Hartford Life & Accident Ins. Co., No. 3:25-CV-297-CHB, 2026 WL 2925146 (W.D. Ky. Sept. 29, 2026) (Judge Claria Horn Boom). Debra Wright, an employee of Sazerac Distillers, LLC and Sazerac Company, Inc. (manufacturers of Buffalo Trace bourbon, among other spirits), elected dependent life insurance on her husband, Dannie Wright, under Sazerac’s ERISA-governed benefit plan, which was insured by a group policy issued by Hartford Life and Accident Insurance Company. The policy provided that dependent coverage ends “the date the Dependent no longer meets the definition of Dependent,” and it defined “Spouse” as a spouse who “is not legally separated or divorced from” the employee, unless coverage was “continued in accordance with” the policy’s continuation provisions. The couple divorced in 2023. Wright alleged that when she asked human resources and a benefits hotline what to do about her benefits, she was told that she could not stop her elections, that premiums would continue to be deducted until the next open enrollment in November 2024, and that the coverage would remain in force. Dannie Wright died on July 24, 2024, and Hartford denied the claim and her appeal because the two were divorced when he died. The Sazerac defendants refunded her premiums through her paycheck, and an HR employee acknowledged that employees or agents had made a mistake in what they told her. Wright thus brought this action, asserting a claim for benefits under ERISA § 502(a)(1)(B) against Hartford and the plan (Count I) and a claim under § 502(a)(3) against the Sazerac defendants for “breach of fiduciary duty and other equitable relief” (Count II). Hartford moved to dismiss Count I, and the Sazerac defendants moved to dismiss both counts. The court considered the policy and plan documents attached to the motions because the complaint referred to them and they were central to her claims. Count I failed on the plain language. The court held that the policy terms were unambiguous, since a policy is ambiguous only if susceptible to multiple reasonable interpretations, “not just because clever lawyers can disagree over the meaning of terms.” Wright did not dispute that coverage ended on divorce, but argued that it continued under § 5.8(C)(2) of the plan, which lets an employee revoke an election after a “Change in Status” such as divorce, and that she never revoked it. The court rejected this, finding that the section governs elections and does not provide for continuation of coverage. It also found that § 3.3, which addresses when an employee stops being eligible to participate in the plan, did not assist Wright because that section “governs an employee’s eligibility to participate in the Plan; it does not address an employee’s eligibility to receive specific elected benefits.” The court therefore dismissed Count I. The court resolved Count II on whether Wright had alleged entitlement to available equitable relief. It declined to treat her catch-all request for “equitable relief” as sufficient, holding that § 1132(a)(3) does not allow monetary relief from fiduciaries for losses caused by a breach. Wright said she did not seek “money damages,” but the court found that surcharge constitutes monetary compensation and thus her claim was barred pursuant to the Sixth Circuit’s interpretation of § 1132(a)(3) in Aldridge v. Regions Bank (the case of the week in our July 23, 2025 edition and currently pending cert review by the Supreme Court). On estoppel, the court applied the Sixth Circuit’s eight-element test. Wright did not allege intended deception or gross negligence amounting to constructive fraud, intent that she rely on the statement, or extraordinary circumstances such as affirmative misconduct or repeated assurances. As for reformation, that doctrine requires mutual mistake or fraud or inequitable conduct by the other party, but Wright alleged only a unilateral mistake, and did not allege that she lacked access to the plan documents or investigated and reasonably relied on the misstatement. Finally, unjust enrichment/restitution requires particular funds in the defendant’s possession, but Wright’s premiums had been refunded in full and her allegations that they were traceable to unspecified plan assets were too vague. As a result, the court granted the two motions to dismiss.
Medical Benefit Claims
Second Circuit
Doe v. Deloitte LLP Group Ins. Plan, No. 23 Civ. 4743 (JPC), 2026 WL 2925729 (S.D.N.Y. Sept. 29, 2026) (Judge John P. Cronan). John Doe is a participant in a health plan sponsored by his employer, Deloitte LLP, and administered by Aetna Life Insurance Company. In this action he seeks coverage for his ten-year-old son A.D.’s residential treatment at Sandhill Center, an out-of-network facility in New Mexico. After A.D.’s seventh hospitalization, his treatment team recommended long-term residential care. The plan states that “Out-of-Network care is not a covered expense,” but allows Aetna, in its “sole discretion,” to offer benefits for services that would not otherwise be covered. Aetna decides whether to approve out-of-network single case agreements using the “ALIC Criteria,” which the plan does not describe. Aetna initially suggested several in-network residential treatment centers, but Doe’s family and educational consultant rejected them. Aetna told the family before admission that Sandhill did not satisfy ALIC criteria because Sandhill lacked accreditation, round-the-clock licensed behavioral health staffing, weekly psychiatric treatment, and a psychiatrist as medical director. Regardless, A.D. was admitted to Sandhill, and Aetna denied the claim and two appeals with the explanation that the plan did not cover out-of-network care. Doe sued under ERISA § 502(a)(1)(B), and last year the court held that Aetna’s denial was arbitrary and capricious because Aetna merely denied on an “out-of-network” basis without ever addressing whether to authorize a single case agreement. The court remanded for a new review. (This decision was Your ERISA Watch’s case of the week in our March 5, 2025 edition.) On remand, Aetna denied the claim again. It concluded there was no network deficiency because there were suitable in-network options, and that Sandhill failed the ALIC Criteria in any event. The dispute returned to court and the parties again cross-moved for summary judgment. Doe argued for de novo review on the ground that the summary plan description (SPD), which contained a grant of discretionary authority, was not “the Plan.” The court acknowledged that SPDs “do not themselves constitute the terms of the plan,” but found that here the SPD “is the only document in the record describing Plaintiff’s coverage” and “[t]he parties agree that this document describes the Plan,” and thus, under Second Circuit precedent, the SPD “is the ‘plan’ for purposes of this action.” The court further explained that its earlier finding of arbitrary and capricious review did not now mandate de novo review. “Aetna’s failure to provide a full and fair explanation initially, which it rectified in the appeal on remand…is [] not a basis for rejecting deferential review.” Next, the court ruled that Aetna’s remand decisions gave Doe a full and fair review under 29 U.S.C. § 1133. Aetna had considered and rejected his single case agreement request and his arguments about the in-network facilities. On the merits, the court held that substantial evidence supported Aetna’s network deficiency finding. Doe’s objections to the in-network facilities fell into three groups: that they would not admit A.D., that admission would be unreasonably delayed, and that their treatment was inappropriate. The court rejected the first because contemporaneous notes, including those of Doe’s own consultant, showed that two facilities would take A.D. despite his age and diagnoses. On delay, it agreed that one facility was likely unavailable, but rejected Doe’s claim about another as “a misleading recitation of the record.” The court accepted that one facility was a “close[] call” on appropriateness, but the court did not need to resolve it, because substantial evidence supported Aetna’s conclusion that two of the facilities were suitable. Doe further relied on A.D.’s treatment providers, who had recommended Sandhill, but the court held that Aetna did not have to “afford ‘special deference’” to their opinions. The court also held that Aetna could rely on the ALIC Criteria, finding that ERISA does not bar external guidelines where the administrator has discretion. The criteria addressed the “appropriateness” and “efficacy” of a treatment “setting” and thus filled a gap in how Aetna exercised its discretion to offer out-of-network benefits without narrowing coverage. Finally, the court did not decide whether the ACA network adequacy regulation, 45 C.F.R. § 156.230, or N.Y. Insurance Law § 3241(a), applied to this self-funded plan. Even if either did, Aetna had explained why it would deny benefits regardless of network adequacy, and those conclusions were supported by substantial evidence. The court thus granted Aetna’s motion for summary judgment and denied Doe’s.
Third Circuit
Ahuja v. Aetna, Inc., No. 25-17642 (SDW) (CF), 2026 WL 2924483 (D.N.J. Sept. 29, 2026) (Judge Susan D. Wigenton). Amit Ahuja, a participant in an ERISA-governed health plan administered by Aetna Life Insurance Company, was hospitalized in Quito, Ecuador in 2022 and medically transported by air ambulance to a Florida hospital. His father, Sunil Ahuja, paid the air ambulance provider $47,990 by bank transfer before the flight. Aetna reimbursed some out-of-pocket expenses but denied coverage for the air ambulance as not medically necessary, and the denial was upheld after two appeals. Amit and Sunil sued for wrongful denial of benefits and breach of fiduciary duty, and Aetna moved to dismiss for lack of standing under Rule 12(b)(1). The court first held that Sunil lacked statutory standing because he was neither a “participant” nor a “beneficiary” under § 502(a). His status as the plan sponsor’s principal shareholder did not matter, and the regulation allowing an authorized representative to pursue claims and appeals, 29 C.F.R. § 2560.503-1(b)(4), “applies to internal submission of claims and appeals,” not federal lawsuits. As for Amit, who did have statutory standing, the court found no Article III injury in fact. Because the air ambulance provider, not Aetna, had demanded payment, and Sunil had already paid it in full, Amit’s alleged injury was neither concrete, since Amit faced no “ongoing exposure,” nor particularized, because it was Sunil who could not recover the $47,990. The court refused to credit plaintiffs’ assertion in their briefing that Amit faced an unreimbursed bill, noting that “a complaint may not be amended by the briefs in opposition to a motion to dismiss.” Ultimately, “[t]he unfortunate reality is that by making the initial payment to Advanced Air, Plaintiffs excluded themselves, albeit unknowingly, from the process and protections Congress made available to patients in situations precisely like Plaintiffs,’” referring to the cost-sharing and dispute resolution protections of the No Surprises Act. The court thus granted Aetna’s motion to dismiss for lack of subject matter jurisdiction.
Seventh Circuit
Christopher E. v. Health Care Service Corp., No. 24-cv-13175, 2026 WL 2936540 (N.D. Ill. Sept. 30, 2026) (Judge Steven C. Seeger). In early 2022, W.E. spent more than two months in Second Nature’s outdoor therapy program in Utah, which combines backpacking with therapy for young adults with mental health, behavioral, and substance abuse problems. The bill exceeded $50,000. W.E. was covered through his father, Christopher E., under the Discover Financial Services Welfare Benefits Plan, which was administered by Blue Cross and Blue Shield of Illinois. Blue Cross denied the claim, and after Christopher appealed, arguing that the treatment was covered and that the denial violated the Mental Health Parity and Addiction Equity Act, it upheld the denial, explaining that “[t]he plan does not cover any behavioral modification facilities. This includes wilderness programs.” Plaintiffs sued Blue Cross and the plan, asserting a claim for benefits under ERISA § 502(a)(1)(B) and a claim under the Parity Act. They alleged that Second Nature was a “Provider” offering “Covered Services” and that Blue Cross also committed procedural deficiencies in its review and denial letters. Defendants moved to dismiss for failure to state a claim. The court considered the plan’s benefits booklet, which defendants submitted, because plaintiffs referred to its terms and it was central to their claims. The court began with the principle of “[n]o coverage, no claim.” “Covered Services” was defined as “a service and supply specified in this benefit booklet for which benefits will be provided,” and it extends inpatient mental health benefits to residential treatment centers. But its definition of a residential treatment center excludes “wilderness programs,” it excludes services not specifically mentioned in the booklet, and it separately excludes behavioral health services provided at various facility types, including wilderness programs, except for covered services provided by appropriate providers. The booklet did not define “wilderness programs,” but the court was unpersuaded by plaintiffs’ characterization of Second Nature as a licensed and accredited “outdoor behavioral health program.” The court stated that it was located in Utah, and “[u]nless you’re in a parking lot of a Shake Shack, if you’re in Utah, you’re probably in the wilderness.” Furthermore, the program’s name and its backpacking activities suggested a wilderness program. Ultimately, the court acknowledged that it could not say at the pleading stage whether the term had a specialized meaning, but called plaintiffs’ relabeling “too cute by half.” In any event, this dispute did not matter, because showing that the wilderness exclusion did not apply did not mean the treatment was covered. Plaintiffs fell short on this issue: “Plaintiffs need a foothold in the booklet, but they don’t have a leg to stand on.” The booklet said nothing about an “outdoor behavioral health program,” and the complaint alleged that Second Nature “was not a residential treatment facility.” Plaintiffs also did not identify any other covered category the program fell within, such as a partial hospitalization or intensive outpatient program. Alleging that Second Nature was a “Provider,” or invoking mental health treatment generally, was not enough, as the booklet did not cover “the entire universe.” The court called the accreditation and licensure arguments “a side show,” and said that alleging that the program is not excluded is “no better than saying that it’s not not-covered.” On the Parity Act claim, the court noted that decisions on wilderness therapy are “all over the map” because of differences in plan language, so each case requires its own analysis. Plaintiffs pleaded two violations. The first was that Blue Cross automatically rejects claims submitted under the National Uniform Billing Committee’s revenue code for outdoor behavioral healthcare, which differs from the code for residential treatment centers. The court found it hard to decipher what plaintiffs alleged, because the complaint did not explain how the use of that code fits the Parity Act framework or what comparable medical or surgical code Blue Cross accepts, and it was not obvious that declining coverage under a billing code is a treatment limitation. The second theory, a disparity between mental health and substance abuse coverage, was withdrawn in plaintiffs’ response brief. As a result, the court granted defendants’ motion to dismiss, dismissing Count I for failure to state a claim for coverage under the plan and Count II as insufficiently pleaded. It granted plaintiffs leave to file an amended complaint.
M.P. v. BlueCross BlueShield of Ill., No. 24-cv-02599, 2026 WL 2927715 (N.D. Ill. Sept. 29, 2026) (Judge Andrea R. Wood). M.P. and his daughter, C.P., a beneficiary of the self-funded Arthur J. Gallagher & Co. Benefits Plan, alleged that BlueCross BlueShield of Illinois (BCBS), the plan’s claims administrator, wrongly denied coverage for C.P.’s mental health treatment at Cascade Academy, a Utah-licensed residential treatment center (RTC). BCBS denied the claims because Cascade did not meet the plan’s definition of an RTC, which requires “24 hour onsite nursing services.” Plaintiffs first sued in the District of Utah, asserting a claim for benefits under ERISA § 502(a)(1)(B), a Parity Act claim under § 502(a)(3), and a claim for statutory penalties under § 502(c)(1) for failure to produce plan documents. The Utah court dismissed all three claims, and plaintiffs filed an amended complaint. The court then granted a joint motion by the parties to transfer the case to the Northern District of Illinois, and defendants moved to dismiss once again. This order was the result. On the Parity Act claim, defendants argued that the plan applied the same 24-hour nursing requirement to RTCs and to their medical and surgical counterparts, skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). This argument had persuaded the Utah court, but this court was not sure that the Utah court had considered that “the 24-hour nursing requirement as to SNFs and IRFs was not expressly imposed by the Plan’s language but instead followed from the Plan’s requirement that those facilities be ‘duly licensed by the appropriate governmental authority.’” The court reasoned that this difference allowed a reasonable inference that the plan’s onsite requirement for RTCs is “more restrictive” than the limits on comparable medical and surgical care. Even if the regulations required identical onsite nursing at SNFs, the court held that the source of the requirement mattered. An RTC under the plan must be licensed and also provide 24-hour onsite nursing, while Cascade did not need onsite nursing to obtain its Utah license. The court called the argument that the two facilities are treated equally “a myopic focus on the fact of such requirement,” since onsite nursing is merely one condition of licensure for SNFs but an additional condition for RTCs. The court acknowledged that another case from the district had taken a different view, finding that “equal limitations arising from different sources do not create a disparity in limitations,” but “[r]espectfully,” it was more persuaded by the majority of other courts in the district which had ruled otherwise. The complaint also plausibly alleged a disparity “as applied,” because a licensed Utah RTC is less likely than a licensed SNF to provide onsite nursing, and “generally accepted standards of care” for RTCs do not call for it and only “a very small number” of Utah RTCs offer it. Turning to the benefits claim, the court upheld it, even though plaintiffs conceded that Cascade did not meet the plan’s 24-hour nursing requirement and did not argue that the requirement was ambiguous. The court held that the claim could proceed because it rested on enforcement of a plan term that plaintiffs plausibly alleged violated the Parity Act. On statutory penalties, plaintiffs abandoned their claim against BCBS and the plan, so that part of Count III was dismissed. Against the plan administrator, however, defendants did not dispute that the employer was the proper plan administrator or that the materials requested by plaintiffs fell within the scope of § 1132(c)(1). BCBS’s response to plaintiffs’ request “supports the inference that the document request reached the entities responsible for plan administration. Whether the Plan Admin did in fact receive and ignore the request is a factual question to be resolved at a later stage.” The court thus granted in part and denied in part defendants’ motion to dismiss, dismissing Count III with prejudice as to BCBS and the plan and denying the motion in all other respects.
Ninth Circuit
Jones v. United Behavioral Health, No. 19-CV-06999-RS, 2026 WL 2924591 (N.D. Cal. Sept. 29, 2026) (Judge Richard Seeborg). Mary Jones brought this certified class action against United Behavioral Health (UBH) challenging UBH’s 2017 Level of Care Guidelines, asserting denial of benefits and breach of fiduciary duty claims on behalf of a reprocessing subclass narrowed after the Ninth Circuit’s decision in Wit v. United Behavioral Health (covered in our August 30, 2023 edition). On cross-motions for summary judgment, the court rejected UBH’s several standing challenges to named plaintiff Jones, including its argument that she had assigned away her right to sue, finding that no implied or apparent authority supported the argument that the assignment signed by her mother was valid. The court also ruled that UBH did not meet its burden of showing that assignments to providers defeated class standing. On the merits, the court held that plaintiffs satisfied Wit’s two-prong reprocessing test of showing that (1) UBH’s denials were based on the wrong standard, and (2) they might be entitled to benefits under the proper standard. On the first prong, the narrowed class definition ensured denials were “based on” the 2017 Guidelines rather than other, unchallenged grounds. On the second prong, the court ruled that plaintiffs only needed to show they “might be entitled” to benefits under a proper standard, not prove individualized entitlement in advance as argued by UBH. “Not only would such a scheme be improper under Ninth Circuit law…but it would also decide the issues backwards and render reprocessing itself a useless formality.” On the fiduciary duty claim, the court held that UBH was collaterally estopped by the district court’s undisturbed factual findings in the Wit case. That court found that financial incentives infected UBH’s guideline development, and under the doctrine of offensive nonmutual collateral estoppel, they applied in this case as well. The court also excused exhaustion for most class members as futile, given UBH’s rigid application of the flawed guidelines. Plaintiffs did not prevail on every issue, however; the court granted summary judgment to UBH as to the subset of class members whose plans contractually required exhaustion and who never appealed. Remedies will be decided after further briefing.
Pension Benefit Claims
Tenth Circuit
Phillips v. Boilermaker-Blacksmith National Pension Trust, Nos. 25-3160 & 25-3171, __ F. 4th __, 2026 WL 2917230 (10th Cir. Sept. 29, 2026) (Before Circuit Judges Tymkovich, Bacharach, and Federico). The Boilermaker-Blacksmith National Pension Trust, a multi-employer plan, provides a pension at age 65, but to be considered retired earlier, a participant “must withdraw completely and refrain from employment or self-employment for an employer which performs work in an industry traditionally covered by a Collective Bargaining Agreement,” in a job of the type covered by a collective bargaining agreement or one that involves direct supervision of such jobs. Many boilermakers retired early and began receiving benefits, but some took other jobs, and the trustees concluded that they were no longer entitled to early-retirement benefits, reading the plan to require withdrawal from any work for a company that contributes to a multi-employer pension plan. The boilermakers sued the plan, six trustees, and the board of trustees, alleging improper denial of benefits, breach of fiduciary duty, and violations of procedural requirements. The district court granted the boilermakers partial summary judgment on the benefits claims and some of the fiduciary claims, but granted the defendants summary judgment on the fiduciary claims of other boilermakers as barred by the three-year limitations period. Defendants appealed, and 66 boilermakers cross-appealed. In this published opinion, the Tenth Circuit began with the standard of review. Because the plan gave the trustees “complete discretion to construe, interpret, and apply all terms and provisions of this Plan document,” arbitrary and capricious review applied, although an interpretation that conflicts with unambiguous plan language is by definition arbitrary and capricious. Because the district court had rejected the trustees’ position on three grounds (unambiguous language, late-raised ambiguity, and tax qualification not overriding the plain language), the defendants had to show that all three were wrong. First, the court held that the plan unambiguously refuted the trustees’ interpretation. It reasoned that “withdraw” is a transitive verb, so that the sentence would be “meaningless” without an object, as when “a soldier withdraws from battle or a student withdraws from school.” The plan supplied the object in its two subsections, which describe collective bargaining agreement jobs and their supervision. A boilermaker who quits and joins a sporting goods store, for example, is not disqualified unless that employer’s industry is traditionally covered by a collective bargaining agreement. The trustees suggested that “withdraw completely” was modified only by the introductory phrase about employers, but that ignored the subsections, and the court ruled that defendants’ interpretation “isn’t just unsupported; it’s also impossible to reconcile with the provision as a whole.” Second, the court upheld the district court’s ruling that the defendants had waived ambiguity by raising it for the first time in their reply brief. Third, because the language was not ambiguous in any event, the plan’s directive to preserve tax qualification, which the defendants conceded could matter only if the language were ambiguous, could not override it. On timeliness, the plan required suit within two years of an adverse decision. 29 C.F.R. § 2560.503-1(g)(1)(iv) requires a denial to disclose the claimant’s right to bring a civil action and the applicable time limits, but the plan administrator denied the initial claims of 69 boilermakers without the proper disclosure. Defendants argued that they cured the omissions by disclosing the period in the appeal denials, but the district court found those denials deficient in their own right, because they did not identify the pertinent plan section or adequately explain the reasons. In a footnote, the appellate court rejected the trustees’ concern that the notice could mislead claimants into skipping exhaustion, stating, “we can’t disregard the Department of Labor’s regulations just because we might disagree with them.” The court did not reach defendants’ remaining challenges under 29 U.S.C. § 1054(g) and (h) and § 1056(h)(2)(B), concerning reductions in earned benefits, notice of amendments, and recoupment of overpayments, because the boilermakers had conceded at oral argument that an affirmance on the plan’s meaning would moot them. On the cross-appeal, the Tenth Circuit held that the district court erred in treating the benefit denials as starting the three-year period for breach of fiduciary duty claims under 29 U.S.C. § 1113(2). The period begins only with “actual knowledge of the breach or violation,” and the alleged breach included “a series of misleading statements” and fraudulent concealment of the trustees’ new unwritten restriction. Because the record did not show when the boilermakers learned of that conduct, summary judgment was unwarranted and the court thus reversed. As a result, the appeal was a clean sweep for the boilermakers.
Pleading Issues & Procedure
Second Circuit
Barbieri v. Legg Mason, Inc., No. 21 Civ. 5231 (PGG), 2026 WL 2949368 (S.D.N.Y. Sept. 30, 2026) (Judge Paul G. Gardephe). Belinda Barbieri worked on the product marketing team at Legg Mason & Co., LLC from 2017 to 2020 under an offer letter that hired her “as a temporary employee,” called the assignment “temporary,” set an hourly rate of $85, and said she “may be eligible for certain Company benefits.” She alleged that she nevertheless performed tasks as a full-time permanent employee, was fully integrated into the team, and that managers promised to correct her misclassification. Legg Mason offered its full-time permanent employees a 401(k) plan, an employee stock purchase plan, a paid time off policy, a vacation leave policy, and a severance plan. After Franklin Resources, Inc. acquired Legg Mason in 2020, Barbieri asked for the same benefits as full-time employees, but her request was denied because she was classified as temporary. Her employment was terminated that month without severance. Barbieri thus filed this action, asserting six claims for relief. Defendants moved to dismiss, and during briefing Barbieri withdrew four of her claims, including a second ERISA misclassification claim and a fiduciary breach claim. That left Count II, a claim for denial of benefits under ERISA § 502(a)(1), and Count VI, a claim for wages and fringe benefits under Connecticut law. The court first resolved which plan documents it could consider. Barbieri conceded that the 401(k) plan and severance plan were integral to her complaint but said it was “impossible to tell” whether defendants’ offered copies were authentic. The court considered them, noting that “Plaintiff cannot both rely on these plan documents in the Complaint and in correspondence to the Court and argue that Defendants should be precluded from relying on these same plan documents.” The 401(k) plan excluded from “Covered Employee” status “any individual employed on a temporary, as needed, basis,” with examples such as summer interns and people hired for short-term projects or to fill in for absent employees. Barbieri argued that the phrase turned on the facts of the work, while the defendants said it referred to anyone classified as temporary in an employment contract. The court found that the plan was ambiguous as applied to Barbieri, that her reading was reasonable, and credited her allegations of three-and-a-half years of continuous work doing “everything a full-time permanent employee on the Product Marketing team did.” Defendants’ motion was thus denied as to the 401(k) plan. Barbieri’s claim for severance benefits was less successful. Section 2.8 of the severance plan excluded anyone who performed services on a temporary or contract basis, “including, but not limited to, any individual categorized by the Company as a temporary employee, seasonal worker, an intern or individual with an identified employment end date.” Barbieri argued that the “identified employment end date” clause modified every item in the list, but the court disagreed. The only reasonable interpretation excluded anyone categorized as a temporary employee, and the key employment documents did just that. Thus, Barbieri was not a participant, and her claim for severance benefits failed. As for the stock purchase plan, it excluded only employees working 20 hours or less per week or five months or less per year, and 5 percent stockholders, so it did not exclude temporary employees as the defendants claimed, and the court declined to consider their reply brief argument that she never formally applied. Barbieri likewise stated plausible claims under the paid time off and vacation leave policies, which no party had supplied and which the defendants had identified no provision excluding temporary employees from. Finally, the court rejected Barbieri’s claim for wages and fringe benefits under Connecticut law. The relevant law addresses only fringe benefits payable on termination, and the complaint did not allege that any policy except for the severance plan provided for such payment. (The court did not reach preemption but noted that the defendants’ preemption argument “completely contradicts” their assertion that the plans were not ERISA plans.) As a result, while defendants knocked out some of Barbieri’s claims, her ERISA benefits claim under the 401(k) plan, stock purchase plan, and the paid time off and vacation leave policies will proceed.
Kijewski v. TIAA, No. 25-CV-01779 (JAV), 2026 WL 2944364 (S.D.N.Y. Sept. 30, 2026) (Judge Jeannette A. Vargas). Peter K. Kijewski, proceeding pro se, sued Teachers Insurance and Annuity Association of America (TIAA), The Vanguard Group, Inc., BNY Pershing, and others over penalties the IRS allegedly imposed when he failed to take required minimum distributions (RMDs) from his retirement accounts. The accounts were caught up in a contentious New York divorce proceeding with Kijewski’s ex-wife, in which the state court entered restraining orders barring the parties from dissipating retirement accounts that were potential marital assets. (Pursuant to that action, TIAA froze his accounts and ceased distributions until it received a signed court order or a qualified domestic relations order, and in 2021 it released the hold and paid him the suspended RMDs after no such order arrived. Vanguard restricted his rollover IRA, and the state court later ordered it to issue his RMDs for 2018 through 2023.) Kijewski also sued his ex-wife and the two attorneys who represented her, alleging among other things “fraud” in their fee applications and a failure to steer their client toward a “prompt” settlement. Defendants moved to dismiss under Rules 8, 9, 12(b)(1), and 12(b)(6). Kijewski’s complaint asserted claims under ERISA, but they were difficult for the court to decipher. The court noted that the complaint “is 466 pages in length and consists of 747 paragraphs,” “contains no narrative account of events,” and “quotes at length from various documents, including court orders, court filings, correspondence, without providing any context. Many of the paragraphs are incomprehensible.” The court found that Kijewski violated Rule 8(a)(2), which requires “a short and plain statement of the claim showing that the pleader is entitled to relief,” because it was not evident which acts by which defendants formed the basis of any of his claims. The next question was whether to grant leave to amend. Defendants argued futility under the domestic relations exception and abstention doctrines. The court held that the exception, which is limited to diversity cases that seek a divorce, support, or custody decree, did not deprive it of jurisdiction because Kijewski asserted claims under ERISA and thus presented a federal question. Abstention was potentially implicated, but the court could not conclude that the claims merely sought to redistribute marital assets or challenge state court orders, given that it lacked the state court orders and could not tell whether they required the account freezes or barred distributions throughout the relevant period. For the same reason, the court could not determine whether the Rooker-Feldman doctrine applied. As a result, the court allowed Kijewski to replead, but excluded his claims against his ex-wife’s attorneys, noting that “an attorney does not owe a duty of care to an adversary.” The claims against them were dismissed with prejudice.
Third Circuit
Clark v. DaVita Inc., No. 26-0023, 2026 WL 2958355 (E.D. Pa. Oct. 1, 2026) (Judge Karen S. Marston). Joy Lucretia Clark worked for DaVita Inc. as a Patient Care Technician and participated in its ERISA-governed employee benefits plan. After developing serious medical conditions, she took a medical leave of absence that DaVita approved as an Americans with Disabilities Act accommodation through December 31, 2025. She had not elected long-term disability coverage, so the leave was unpaid. Clark alleged that DaVita later “processed her employment as terminated” for failing to provide sufficient information about the expected length of her leave, but that the termination notice was returned as undeliverable and DaVita reinstated her, with a case manager writing that “the system views it as never having happened.” Clark also alleged that she had difficulty obtaining benefits records and information from DaVita, Prudential Insurance Company of America, which issued or administered group insurance benefits, and Alight Solutions LLC, which provided plan recordkeeping and administrative services. As of now, it appears Clark “has remained on approved unpaid ADA leave because of her medical condition and has not returned to work, and she has continued participating in the leave administration process.” Clark filed this pro se action against DaVita, Prudential, and Alight. In June of 2026, the court dismissed the original complaint on screening under 28 U.S.C. § 1915(e)(2)(B)(ii), dismissing Counts V and VI (sufficiency of review and equitable relief) with prejudice, and Counts I through IV without prejudice, and with leave to amend. The court also ordered Clark to show cause why she should not be enjoined from filing certain cases in the future, given that she had filed eleven civil actions in the Eastern District of Pennsylvania within fifteen months, none of which had survived screening. (We covered this ruling in our June 17, 2026 edition.) Clark responded to the order to show cause and filed an amended complaint asserting four counts: failure to disclose plan documents, a claim for a declaration of her rights to benefits, breach of fiduciary duty, and a request for equitable relief. The court remained unimpressed. On the disclosure claim in Count I, the court noted that Clark identified only one written request, and that DaVita’s production came less than thirty days later. “From her own list, it appears that DaVita produced everything that she asked for.” Count I was therefore dismissed with prejudice. Count II sought a “clarification of rights” under the plan without identifying any plan provision, any benefit determination by an administrator, or any basis for the claim. The court observed that Clark still had not alleged that she followed the appeal process for the plan, instead alleging that she “sought clarification.” However, “the statement that she ‘sought clarification’ is not the equivalent of exhaustion.” Nor did Clark plausibly plead futility. The court dismissed Count II without prejudice to Clark pursuing available remedies outside of court, but without leave to amend because further amendment would be futile. The breach of fiduciary duty claim in Count III failed because Clark did not allege facts about the plan’s provisions or the duty owed to her, did not identify the breach, and did not allege any loss to the plan. Count IV, for equitable relief, was a “repackaged version” of the count the court had previously dismissed with prejudice and was dismissed on that basis. As for the order to show cause, the court found exigent circumstances in Clark’s eleven “groundless” filings in fifteen months. The court noted that even though it had warned her in another case that continued abuse could lead to denial of in forma pauperis status, she subsequently filed four more cases in the space of two months. Her response to the show cause order, asserting that she “filed each action based upon a genuine belief that her legal rights have been affected,” did not sway the court. As a result, Clark was enjoined for two years “from filing new civil, non-Social Security or non-habeas matters on an in forma pauperis basis unless she includes with her complaint and in forma pauperis application (1) a certification indicating that the claims she seeks to present have arguable merit (2) that is signed by a licensed attorney, and (3) includes that attorney’s bar number and contact information.”
Fifth Circuit
Dukes v. Sun Life Assurance Co. of Canada, No. 25-623-EWD, 2026 WL 2963507 (M.D. La. Sept. 30, 2026) (Magistrate Judge Erin Wilder-Doomes). Kevin Dukes, who is incarcerated and proceeding pro se, sued Sun Life Assurance Company of Canada in Louisiana state court for long-term disability benefits under a policy issued by Sun Life to his former employer, IRISNDT Inc. His complaint did not mention ERISA and claimed $725,618 in damages, plus penalties and fees. Sun Life removed the case to federal court, asserting federal question jurisdiction based on ERISA, and, alternatively, diversity jurisdiction. Previously, the court denied Dukes’s motions to remand and for sanctions, and granted Sun Life’s motion to dismiss his state law claims as preempted by ERISA, without leave to amend. (We covered this ruling in our December 17, 2025 edition.) Dukes followed up with three motions: one styled as a motion for reconsideration and for leave to file a First Amended Complaint, which attached a proposed pleading asserting ERISA claims under § 502(a)(1)(B) and § 502(a)(3); a “Jurisdiction-First Motion for Determination of Subject-Matter Jurisdiction”; and a motion for limited jurisdictional discovery seeking the policy, plan description, and related documents. Sun Life opposed all three, arguing among other things that the proposed amendment recast Dukes’s state law contract claim, that the § 502(a)(3) claim was unsupported, and that Dukes was pursuing the amendment in bad faith or with a dilatory motive. The court quickly disposed of the jurisdictional motions. Whether ERISA applies was “irrelevant” because the court independently had diversity jurisdiction for the reasons given in its December ruling, and Dukes’s position was in any event inconsistent with his own motion to amend, which sought to assert claims under ERISA. Jurisdictional discovery was unnecessary because the court’s case management order already required Sun Life to file the plan, the summary plan description, and the administrative record. The court also found that Dukes did not truly seek reconsideration, as the December ruling barred only further amendment of the state law claims. As for leave to amend, the court allowed Dukes to plead a § 502(a)(1)(B) claim. The motion came less than a month after the dismissal ruling, no scheduling order deadlines were in place, Dukes had not previously amended, and Sun Life identified no undue prejudice, particularly because that claim was the basis of its own removal. The court gave little weight to Sun Life’s concern that Dukes was recasting his dismissed contract claims, and it rejected the argument that the forthcoming administrative record made amendment pointless. The court did observe that Dukes’s “motive for originally filing the Petition that fails to mention ERISA does seem like gamesmanship under the circumstances,” but because he now accepted that ERISA governs, it found no bad faith or dilatory motive. Dukes’ § 502(a)(3) claim did not fare as well. The court explained that § 502(a)(3) is a “catchall” provision that acts “as a safety net, offering appropriate equitable relief for injuries caused by violations that § 502 does not elsewhere adequately remedy,” and is designed to prevent claimants from “repackag[ing]” benefit claims as breach of fiduciary duty claims. Here, Dukes’s proposed second cause of action alleged that Sun Life breached duties of loyalty and prudence by failing to provide a full and fair review, misapplying an “incarceration-related limitation or exclusion,” failing to consider his Social Security disability determination, and ignoring a written demand. The court found these allegations to be “exactly the type of attempt to repackage a denial of benefits claim as a breach of fiduciary duty claim courts have cautioned against.” Dukes’s request for an “equitable surcharge” did not change the result, as “the label used is not controlling”; a surcharge to compensate for losses caused by fiduciary breaches “would be the equivalent of compensating Plaintiff for the lost LTD benefits.” As a result, Dukes will be allowed to bring a claim under § 502(a)(1)(B), but all of his other arguments were rejected.
Provider Claims
Second Circuit
Jay Kripalani M.D., P.C. v. United HealthCare Group, No. 2:24-cv-5671 (NJC) (JMW), 2026 WL 2924534 (E.D.N.Y. Sept. 29, 2026) (Judge Nusrat J. Choudhury). Dr. Jay Kripalani, an out-of-network provider, performed emergency medical services on a patient identified as K.R., a Florida resident covered by a self-funded health plan maintained by K.R.’s employer and administered by United HealthCare Group. Kripalani billed usual and customary charges of $1,536,884. After several rounds of telephone negotiations, United Healthcare made what Kripalani called a “random and arbitrary payment” of $15,910.70, leaving Kripalani to seek the remainder in this action alleging both ERISA and state law claims. United moved to dismiss, and the court referred the motion to a magistrate judge, who recommended that the motion be granted. Both sides objected to portions of the report, and this order was the result. First, on Kripalani’s ERISA claim, the court held that it could consider the plan when evaluating United’s standing challenge because the complaint, which referenced the plan more than seven times and premised the claim on United’s status as administrator, made the plan integral to the pleading. That plan contained an anti-assignment provision stating that rights and benefits “cannot be assigned, sold, or transferred to a third party, including your health care provider,” that “[a]ny purported assignment of rights or benefits is void,” and that the claims administrator’s direct payment to a provider “does not create an assignment of benefits and it will not constitute a waiver” of the provision. Kripalani conceded that he was neither a participant nor a beneficiary, and thus his standing depended on holding a valid assignment from his patient and a waiver of the plan’s anti-assignment clause. The complaint alleged neither. Even crediting Kripalani’s argument that he told United he was an assignee and that United never objected, the court held that this did not plausibly allege a “clear and unmistakable” waiver. Kripalani’s ERISA claim was therefore dismissed under Rule 12(b)(1). Turning to Kripalani’s unjust enrichment claim, the court agreed with the magistrate that it could exercise diversity jurisdiction, given the parties’ diverse citizenship and the more than $1.5 million at stake, but concluded that ERISA preempted the claim. The claim, the court reasoned, “not only relates to the Plan but is rooted in it,” because the complaint alleged that K.R. was insured by a self-funded plan administered by United and that United “‘is wrongfully in possession of the Amounts Due’ because of its obligation to pay healthcare providers on behalf of plan beneficiaries.” In short, “Kripalani would not have a claim for unjust enrichment without the Plan.” The court also rejected Kripalani’s argument that a complaint cannot both fail to state an ERISA claim and be preempted by ERISA, pointing to cases from the district that had ruled in precisely that manner. Although the report recommended dismissal with prejudice, the court granted leave to amend under Rule 15(a)(2). It acknowledged that it was “not clear” that Kripalani could cure the lack of standing or plead an unjust enrichment claim untethered from the plan, but reasoned that courts should generally permit amendment at least once after articulating their substantive concerns. Kripalani was warned, however, that he “is unlikely to be afforded any further opportunity to amend absent unforeseen and extraordinary circumstances.”
Fifth Circuit
Methodist Healthcare Sys. of San Antonio, Ltd., LLP. v. Community Ins. Co., No. 3:25-cv-01615-E, 2026 WL 2969612 (N.D. Tex. Oct. 1, 2026) (Judge Reed O’Connor). A group of Texas acute care hospital systems, led by Methodist Healthcare System of San Antonio, have contracts with non-party Blue Cross and Blue Shield of Texas (BCBSTX). These contracts set the terms and rates for treating patients covered by Blue Cross and Blue Shield plans across the country, including patients insured by out-of-state Blue licensees through the BlueCard Program. Under that program, when a subscriber insured by a “Home Plan” in one state receives care in another state, the local “Host Plan” reviews the claim and prices it under its provider contract, and the Home Plan makes the final coverage determination and pays. Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (Anthem), the Blue licensee for Ohio, was the Home Plan for nine subscribers who received treatment at the Texas hospitals. The hospitals alleged that (1) Anthem is bound by the agreements as an affiliate of BCBSTX and through its participation in the BlueCard Program, (2) Anthem dealt directly with the hospitals rather than through BCBSTX, and (3) Anthem represented the hospitals as in-network providers on its website. The subscribers assigned their claims to the hospitals, which sued Anthem in the Northern District of Texas, asserting five counts under ERISA and state law. Anthem moved to dismiss under Federal Rule of Civil Procedure 12(b)(2), asserting lack of personal jurisdiction. The parties agreed that the court had nationwide personal jurisdiction over the ERISA count under 29 U.S.C. § 1132(e)(2), so the dispute concerned whether the court could exercise personal jurisdiction over the state law claims, either directly through specific jurisdiction or through pendent jurisdiction attached to the ERISA claim. The court acknowledged Fifth Circuit cases reflecting the rule that “[i]nsurance companies do not subject themselves to specific jurisdiction by simply participating in a national insurance program such as the [Blue Card Program] that pays hospitals when their insured gets treatment at an out-of-state hospital.” However, the court found these authorities distinguishable because the hospitals alleged that Anthem “insures and/or administers health plans that cover Texas residents” and that the Texas residents received care in Texas. Along with Anthem’s website listing of Texas hospitals as in-network, the court concluded that Anthem purposefully directed its activities at Texas, holding that parties who “reach out beyond one state and create continuing relationships and obligations with citizens of another state” are subject to regulation and sanctions there. In short, “When an insurance company takes on the continuing responsibility of insuring residents of another state, that state has specific jurisdiction over claims arising out of that contact.” As for pendent jurisdiction, the court explained that a state law claim must share a “common nucleus of operative fact” with the federal claim, and agreed with Anthem “in part” that the common thread among the claims, namely that all of the subscribers were insured by Anthem, was not enough. The court noted that plaintiffs’ claims involved four hospitals and nine subscribers, each with a separate health plan. The court reasoned that the hospitals could establish a common nucleus for state law claims assigned by the same subscriber who assigned the ERISA claim, because those claims would arise from the same patient, the same hospital, and the same treatment. The court would not exercise pendent jurisdiction over claims from subscribers who did not assign an ERISA claim, so any such claims would have to rest on independent specific jurisdiction. Finally, the court agreed with Anthem that the complaint was defective because it did not distinguish between claims arising under ERISA-governed plans and those arising under plans exempt from ERISA, or identify which subscribers were Texas residents. The court gave plaintiffs leave to amend, with instructions, for each claim, to allege whether jurisdiction rests on specific jurisdiction based on Anthem’s insuring of Texas residents or on pendent jurisdiction tied to a subscriber’s ERISA claim.
Retaliation Claims
Seventh Circuit
Alwin v. Gypsum Mgmt. Supply, Inc., No. 26-C-224, 2026 WL 2937515 (E.D. Wis. Sept. 30, 2026) (Judge William C. Griesbach). Gabriel Alwin, proceeding pro se, alleges that he underwent emergency surgery, was placed on Family and Medical Leave Act (FMLA) leave, and was approved for short-term disability benefits. Shortly after his short-term disability period ended and while he remained medically disabled and benefit-eligible, his employer terminated him under a “three-day no-call/no-show” policy, which he alleged was inconsistent with past practice because the company knew he was on medical leave and never tried to contact him. His union, Teamsters Local Union No. 200, declined to pursue his grievance. As a result, Alwin brought this action against his employer (through three entities: Gypsum Management Supply, Inc., Badgerland Supply, and Tamarack Materials) and the union, asserting a “hybrid § 301 claim” under the Labor Management Relations Act, an FMLA claim, a Wisconsin workers’ compensation retaliation claim, and, against the company defendants, a claim under ERISA § 510 for interfering with his benefits. Defendants moved to dismiss for failure to state a claim. On the ERISA claim, the court stated that a § 510 plaintiff “must establish more than a loss of benefits” and must demonstrate that the employer acted with the specific intent of preventing or retaliating for the use of benefits, meaning a “desire to frustrate attainment or enjoyment of benefit rights.” Alwin’s only allegations were that he was receiving short-term disability benefits and was eligible for long-term disability and continued health and retirement benefits, that defendants knew this, and that they “terminated Plaintiff for the purpose of interfering with his attainment of ERISA-protected benefits.” The court found these to be “bare legal conclusions,” with no factual allegations supporting an inference that defendants intended to deprive him of benefits. The court also noted that Alwin did not plead exhaustion of administrative remedies and did not respond to defendants’ exhaustion argument. However, it declined to decide whether exhaustion must be pleaded, citing a split among courts in the circuit, because the claim failed on the merits anyway. Plaintiffs’ other claims met the same fate. The hybrid § 301 claim was untimely under the six-month limitations period, because Alwin sued almost two years after the union’s letter and did not plausibly plead grounds for equitable tolling. The FMLA claim failed because he did not allege eligibility, his own allegations showed he could not return to work well beyond twelve weeks, and he was terminated at least three months after his leave would have been exhausted. The workers’ compensation claim was dismissed because Alwin did not oppose dismissal, seemingly accepting that such a claim is best pursued with the Wisconsin Department of Workforce Development. In the end, the court granted the motions to dismiss but, because Alwin was proceeding pro se, gave him 30 days to file an amended complaint.
Statute of Limitations
Fourth Circuit
David B. v. Anthem Blue Cross & Blue Shield, No. 1:24-cv-01551 (PTG/IDD), 2026 WL 2924511 (E.D. Va. Sept. 29, 2026) (Judge Patricia Tolliver Giles). David B. sued on his own behalf and for his minor daughter, R.B., challenging Anthem Blue Cross and Blue Shield’s denial of coverage for her residential mental health treatment in 2021. Anthem, the insurer and claims administrator of his ERISA-governed benefit coverage, denied the treatment as not medically necessary in letters dated February 15, March 2, and March 15, 2021, and denied his appeal in a final letter dated August 26, 2021. Each letter told him that he had the right to bring a civil action under § 502(a)(1)(B) “within one year, unless your plan provides for a longer period,” and to “[c]heck your benefits booklet or plan documents to see if you have more time.” David B. then sought external review through the Virginia Bureau of Insurance, which upheld the denial in a report dated January 27, 2022. He filed suit in the District of Utah on February 9, 2024, asserting a claim for benefits under ERISA § 502(a)(1)(B) and a Parity Act claim under § 502(a)(3). The case was transferred to the Eastern District of Virginia, which denied Anthem’s partial motion to dismiss, and the parties cross-moved for summary judgment. Review was for abuse of discretion because the policy gave Anthem “complete discretion” to administer benefits, including by determining medical necessity and construing the contract. The court first examined the threshold question of whether the claims were time-barred. Two provisions of the certificate were at issue. The “Legal Action” subsection of the general provisions barred any action brought “more than three years after the end of the 90-day period that proof of loss was required to be filed.” Meanwhile, the “Limitation of Actions” subsection of the appeal procedures provided that, for an ERISA plan, the member has “a right to bring a civil action under Section 502(a) of ERISA within one year of the appeal decision.” David B. argued that the two provisions conflicted, the certificate was therefore ambiguous, and contra proferentem required applying the three-year period. Anthem argued that both provisions applied because they are triggered by different events, so a plaintiff must satisfy both. The court agreed with Anthem, employing the Tenth Circuit’s approach in J.H. v. Anthem Blue Cross Life & Health Ins. Co., which construed nearly identical language. (Your ERISA Watch covered J.H. in our May 28, 2025 edition.) The three-year provision warns the insured to sue within three years of when proof of loss had to be furnished, and the one-year provision “simply adds another deadline,” so a suit is barred “[i]f the insured files suit after either deadline.” The court rejected the argument that only one limitations provision can govern a dispute, and held that the language was not ambiguous “just because the Plan imposes two conditions.” As the court put it, “the provision is meant to limit suits, not invite them. If the two limitations provisions were interpreted to give Plaintiff two different windows for filing suit, there would be no point in having a one-year limitations period, since the three-year provision would always supersede it.” The court added that the result would be the same even if the certificate were ambiguous. Contra proferentem does not apply where, as here, the plan gives the claims administrator discretion to interpret its terms and review is deferential. The one-year provision applies by its terms to § 502(a) actions and Anthem’s letters had pointed him to the one-year period and told him to consult his plan documents. In a footnote, the court rejected the argument that the letters mentioned only § 502(a)(1)(B), reasoning that the certificate covers all § 502(a) claims and that David B. did not argue he relied on the letters. In another, it held that even if the external reviewer’s 2022 report were treated as the final determination, the suit would still be untimely. Anthem’s motion for summary judgment was thus granted, and David B.’s was denied.
Fifth Circuit
Thomas v. Amazon.com Services, Inc., No. 4:21-CV-02997, 2026 WL 2934940 (S.D. Tex. Sept. 29, 2026) (Judge Drew B. Tipton). Michel Thomas worked as an associate at an Amazon warehouse near Houston and was covered by the AmazonTXCare Employee Injury Benefit Plan, for which Amazon was the plan administrator and Anchor Risk Management the claims administrator. He suffered three work injuries in 2019 and sought benefits for each. Anchor terminated his benefits for the first injury after an independent medical examination (IME) found age-related degeneration and no need for further treatment. It denied his second claim on the ground that he had only aggravated the first injury. It denied the third claim as untimely. Amazon fired Thomas in 2019 and he brought this pro se action in 2021, claiming benefits under ERISA § 502(a)(1)(B) and penalties under § 502(c) for failure to give him the plan or a summary plan description. The court held a bench trial and this order represented the court’s ruling. Amazon argued that the denial claims were barred by Article 6.13 of the plan, which required suit within one year of the final appeal decision. The court held that the one-year period was reasonable. However, it was unenforceable because Thomas’s claims were for disability benefits, and 29 C.F.R. § 2560.503-1(j)(4)(ii) requires final disability determinations to disclose the contractual limitations period and “the calendar date on which the contractual limitations period expires,” and the plan must “strictly adhere” to the claims rules. On the first injury, the record did not contain the final denial letter, so there was no evidence to show that it disclosed either the period or its expiration date, and the third injury letter disclosed neither. Thus, the court declined to enforce the period. The second injury was “narrower,” because that letter did state the one-year period but omitted the calendar date. No circuit had decided that question, but the regulation treated the two as “distinct requirements” and thus the court concluded that both must be included in order to be enforceable. Because the plan’s period was unenforceable, the court applied Texas’s four-year contract limitations period, under which Thomas’s suit was timely. On the merits, the court reviewed Amazon’s determinations for abuse of discretion. The termination of benefits for the first injury stood. The IME doctor’s report constituted “substantial evidence,” and Amazon could credit it over the contrary views of Thomas’s urgent care clinic. Thomas argued that the IME doctor was not an “Approved Provider,” but the plan lets the administrator approve providers and it was not unreasonable to read “care or treatment” to include the IME. The denial for the second injury was an abuse of discretion. It rested on the absence of a new “Accident,” but Articles 4.5 and 4.6 cover injuries from “an Accident, Occupational Disease and/or Cumulative Trauma,” and Anchor’s own adjuster described the condition as “more of a cumulative-type problem.” Treating the lack of an accident as dispositive effectively read one of the plan’s covered categories out of the plan. Thomas nevertheless recovered nothing on that claim, because he offered no evidence of unpaid medical expenses or of disability benefits beyond the short-term benefits he received. The denial for the third injury was upheld because Thomas’s own report said he was injured eleven days before he reported it, and Article 3.3 required reporting within three days. On the document claim, the court held that only Amazon, as the designated plan administrator, could be liable under § 1132(c). Thomas requested the plan in writing on July 8, 2019, and Anchor’s adjuster emailed it as an attachment on July 30, but the court credited Thomas’s testimony that he could not open the attachments. Under 29 C.F.R. § 2520.104b-1, administrators must use measures “reasonably calculated to ensure actual receipt.” Amazon did not mail the plan within thirty days or show that the email satisfied the electronic delivery safe harbor, and the adjuster used no safeguard and never followed up. The court declined to award a penalty for the summary plan description because Thomas never made a written request for it. Finding negligence but no bad faith, a substantial delay, and prejudice because the missing plan impaired his ability to challenge the second denial, the court awarded $6,050.
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