Justia U.S. 9th Circuit Court of Appeals Opinion Summaries

Several individuals, representing a class, challenged a health insurance company’s refusal to cover gender-affirming care for transgender individuals diagnosed with gender dysphoria. The company, acting as a third-party administrator for employer-sponsored, self-funded health plans, denied coverage for such treatments based on explicit plan exclusions requested by the employer sponsors. Some plaintiffs also alleged that they were denied coverage for treatments that would have been covered for other diagnoses, such as precocious puberty, but were denied solely because of the concurrent diagnosis of gender dysphoria.The United States District Court for the Western District of Washington certified the class and granted summary judgment in favor of the plaintiffs. The district court rejected the company’s arguments that it was not subject to Section 1557 of the Affordable Care Act because its third-party administrator activities were not federally funded, that it was merely following employer instructions under ERISA, and that it was shielded by the Religious Freedom Restoration Act (RFRA). The district court also found that the exclusions constituted sex-based discrimination under Section 1557.On appeal, the United States Court of Appeals for the Ninth Circuit agreed with the district court that the company is subject to Section 1557, that ERISA does not require administrators to enforce unlawful plan terms, and that RFRA does not provide a defense in this context. However, the Ninth Circuit held that the district court’s analysis of sex-based discrimination was undermined by the Supreme Court’s intervening decision in United States v. Skrmetti, which clarified the application of sex discrimination standards to exclusions for gender dysphoria treatment. The Ninth Circuit vacated the summary judgment and remanded the case for further proceedings to consider whether, under Skrmetti, the exclusions at issue may still constitute unlawful discrimination, particularly in cases involving pretext or proxy discrimination or where plaintiffs had other qualifying diagnoses. View "PRITCHARD V. BLUE CROSS BLUE SHIELD OF ILLINOIS" on Justia Law

Robert Platt, an employee of Sodexo, Inc., sued his employer, claiming that a monthly tobacco surcharge on his employee health insurance premiums violated the Employee Retirement Income Security Act (ERISA). Platt brought claims on behalf of himself and other plan participants to recover losses under ERISA § 502(a)(1)(B) and § 502(a)(3), and a breach of fiduciary duty claim on behalf of the employer-sponsored health insurance plan (the Plan) for losses under ERISA § 502(a)(2). Sodexo sought to compel arbitration based on an arbitration provision it unilaterally added to the Plan after Platt joined.The United States District Court for the Central District of California denied Sodexo’s motion to compel arbitration, holding that there was no enforceable arbitration agreement because Sodexo unilaterally modified the Plan to add the arbitration provision without Platt’s consent. The court found that Platt did not agree to arbitrate his claims.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court agreed that an employer cannot create a valid arbitration agreement by unilaterally modifying an ERISA-governed plan to add an arbitration provision without obtaining consent from the relevant party. The court held that Platt is the relevant consenting party for claims under ERISA § 502(a)(1)(B) and § 502(a)(3) and that he did not consent to arbitration because he did not receive sufficient notice of the arbitration provision. However, the court held that the Plan is the relevant consenting party for the breach of fiduciary duty claim under ERISA § 502(a)(2) and that the Plan consented to arbitration.The Ninth Circuit affirmed the district court’s denial of Sodexo’s motion to compel arbitration for Platt’s claims under ERISA § 502(a)(1)(B) and § 502(a)(3). It reversed in part the district court’s denial of the motion to compel arbitration for the breach of fiduciary duty claim under ERISA § 502(a)(2) and remanded for the district court to consider Platt’s unconscionability defenses and the severability of the representative action waiver and any other arbitration clauses found unconscionable. View "PLATT V. SODEXO, S.A." on Justia Law

Peter Schuman and William Coplin, former employees of Atmel Corporation, were terminated without cause after Microchip Technology Inc. acquired Atmel. They were offered severance benefits significantly lower than those promised under Atmel's Employee Retirement Income Security Act (ERISA)-governed benefits plan, in exchange for signing a release of all potential claims. Schuman and Coplin signed the releases but later filed a class-action lawsuit on behalf of approximately 200 similarly situated former Atmel employees, alleging ERISA violations, including breach of fiduciary duty and denial of benefits, and challenging the enforceability of the releases.The United States District Court for the Northern District of California granted summary judgment in favor of Microchip against Schuman and Coplin, applying a six-part test to determine that the releases were signed knowingly and voluntarily. The court did not consider evidence of Microchip's alleged breach of fiduciary duties in its analysis. The district court denied summary judgment for the non-named plaintiffs, finding material disputes of fact regarding Microchip's knowledge of the Plan's intended interpretation. The court entered final judgment under Federal Rule of Civil Procedure 54(b) for Schuman and Coplin, certifying the question of the appropriate legal test for determining the enforceability of the releases.The United States Court of Appeals for the Ninth Circuit reversed the district court's summary judgment against Schuman and Coplin, holding that courts must evaluate the enforceability of ERISA releases by considering the totality of the circumstances, including any alleged improper conduct by the fiduciary. The court enumerated nine non-exhaustive factors for this evaluation. The case was remanded to the district court for further proceedings consistent with this opinion. The Ninth Circuit dismissed Microchip's cross-appeal for lack of jurisdiction, as the issue raised was not inextricably intertwined with the primary appeal. View "Schuman v. Microchip Technology Inc." on Justia Law

Winston R. Anderson, a former Intel employee, brought a putative class action under the Employee Retirement Income Security Act (ERISA) against the trustees of Intel Corporation’s proprietary retirement funds. Anderson alleged that the trustees breached their fiduciary duty of prudence by investing in hedge funds and private equity funds, and their duty of loyalty by steering retirement funds to companies in which Intel Capital had already invested.The United States District Court for the Northern District of California dismissed Anderson’s claims, concluding that he had not plausibly alleged a breach of either the duty of prudence or the duty of loyalty. The court found that Anderson failed to provide a meaningful benchmark to compare the performance of Intel’s funds and did not plausibly allege a real conflict of interest for the duty of loyalty claim. Anderson was granted leave to amend his complaint, but the district court dismissed the amended complaint with prejudice for the same reasons.The United States Court of Appeals for the Ninth Circuit affirmed the district court’s dismissal. The court held that Anderson did not state a claim for breach of ERISA’s duty of prudence because he failed to provide a sound basis for comparison, as the funds he compared to Intel’s funds had different aims, risks, and potential rewards. The court also held that Anderson did not state a claim for breach of the duty of loyalty because he did not plausibly allege a real conflict of interest, only the potential for one. The court emphasized that ERISA requires prudence based on the methods employed by fiduciaries, not the results achieved, and that generalized attacks on hedge funds and private equity funds as a category are insufficient to state a claim. View "Anderson v. Intel Corporation Investment Policy Committee" on Justia Law

The case involves Bristol SL Holdings, Inc., the successor-in-interest to Sure Haven, Inc., a defunct drug rehabilitation and mental health treatment center, and Cigna Health and Life Insurance Company and Cigna Behavioral Health, Inc. Bristol alleged that Sure Haven's calls to Cigna verifying out-of-network coverage and seeking authorization to provide health services created independent contractual obligations. Cigna, however, denied payment based on fee-forgiving, a practice prohibited by the health plans. Bristol brought state law claims for breach of contract and promissory estoppel against Cigna.The district court initially dismissed Bristol’s claims, but the Ninth Circuit Court of Appeals reversed the dismissal, holding that Bristol had derivative standing to sue for unpaid benefits as Sure Haven’s successor-in-interest. On remand, the district court granted Cigna’s motion for summary judgment, ruling that the Employee Retirement Income Security Act of 1974 (ERISA) preempted Bristol’s state law claims.On appeal, the Ninth Circuit Court of Appeals affirmed the district court's decision. The court held that Bristol’s state law claims were preempted by ERISA because they had both a “reference to” and an “impermissible connection with” the ERISA plans that Cigna administered. The court reasoned that Bristol’s claims were not independent of an ERISA plan because they concerned the denial of reimbursement to patients who were covered under such plans. The court also held that allowing liability on Bristol’s state law claims would interfere with nationally uniform plan administration, a central matter of plan administration. View "Bristol SL Holdings, Inc. v. Cigna Health and Life Insurance Co." on Justia Law

The case involves pension plan participants, Evelyn Wilson and Stephen Bafford, who alleged that the plan administrator, the Administrative Committee of the Northrop Grumman Pension Plan, violated the Employee Retirement Income Security Act (ERISA) by not providing pension benefit statements automatically or on request, and by providing inaccurate pension benefit statements prior to their retirements. The district court initially dismissed the case, but on appeal, the Ninth Circuit Court of Appeals affirmed in part and vacated in part the dismissal, allowing the plaintiffs to file amended complaints.Upon remand, the plaintiffs filed amended complaints, but the district court dismissed their claims again. The plaintiffs appealed once more to the Ninth Circuit Court of Appeals. The Ninth Circuit held that the lower court's prior mandate did not preclude the plaintiffs from pleading their claim for violation of ERISA on remand. The court also held that the plaintiffs stated a viable claim under ERISA by alleging that the plan administrator provided substantially inaccurate pension benefit statements.The court rejected the administrator’s argument that there were no remedies available for the ERISA violations the plaintiffs alleged. As a result, the Ninth Circuit reversed the district court’s dismissal of the plaintiffs’ claims and remanded the case for further proceedings. View "BAFFORD V. ADMINISTRATIVE CMTE. OF THE NORTHROP GRUMMAN PLAN" on Justia Law

The plaintiff, Ryan S., filed a class action lawsuit against UnitedHealth Group, Inc. and its subsidiaries (collectively, “UnitedHealthcare”) under the Employee Retirement Income Security Act of 1974 (“ERISA”). He alleged that UnitedHealthcare applies a more stringent review process to benefits claims for outpatient, out-of-network mental health and substance use disorder (“MH/SUD”) treatment than to otherwise comparable medical/surgical treatment. Ryan S. asserted that by doing so, UnitedHealthcare violated the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“Parity Act”), breached its fiduciary duty, and violated the terms of his plan.The district court granted UnitedHealthcare’s motion to dismiss under Federal Rule of Civil Procedure 12(b)(6) based primarily on its conclusions that Ryan S. failed to allege that his claims had been “categorically” denied and insufficiently identified analogous medical/surgical claims that he had personally submitted and UnitedHealthcare had processed more favorably.The United States Court of Appeals for the Ninth Circuit reversed in part and affirmed in part the district court’s judgment. The panel concluded that Ryan S. adequately stated a claim for a violation of the Parity Act. The panel explained that an ERISA plan can violate the Parity Act in different ways, including by applying, as Ryan S. alleged here, a more stringent internal process to MH/SUD claims than to medical/surgical claims. The panel also concluded that Ryan S. alleged a breach of fiduciary duty. However, as Ryan S. failed to identify any specific plan terms that the alleged practices would violate, the panel affirmed the dismissal of his claims based on a violation of the terms of his plan. The case was remanded for further proceedings. View "Ryan S. v. UnitedHealth Group, Inc." on Justia Law

In this case, the United States Court of Appeals for the Ninth Circuit reversed the district court's dismissal of an ERISA action brought by South Coast Specialty Surgery Center, Inc. against Blue Cross of California, d/b/a Anthem Blue Cross.South Coast, a healthcare provider, sought reimbursement from Blue Cross for the costs of medical services provided to its patients. South Coast argued that although it was not a plan participant or a beneficiary under ERISA, it had the right to enforce ERISA's protections directly because its patients had assigned it the right to sue for the non-payment of plan benefits via an "Assignment of Benefits" form. The district court disagreed and dismissed South Coast's suit, concluding that the form only conveyed the right to receive direct payment from Anthem, and not the right to sue for non-payment of plan benefits.The Ninth Circuit held that a healthcare provider can enforce ERISA's protections if it has received a valid assignment of rights. The court determined that South Coast's patients had effectuated a valid assignment through the "Assignment of Benefits" form. Therefore, South Coast had the right to seek payment of benefits and to sue for non-payment. The court reversed the lower court's decision and remanded the case for further proceedings. View "SOUTH COAST SPECIALTY SURGERY CENTER, INC. V. BLUE CROSS OF CALIFORNIA" on Justia Law

United Behavioral Health (“UBH”) appeals from the district court’s judgment finding it liable to classes of Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001 et seq. (“ERISA”) Plaintiffs under 29 U.S.C. Sections 1132(a)(1)(B) and (a)(3), as well as several pre- and posttrial orders, including class certification, summary judgment, and a remedies order. UBH contends on appeal that Plaintiffs lack Article III standing and that the district court erred at class certification and trial in several respect.   The Ninth Circuit reversed in part. The panel held that Plaintiffs had Article III standing to bring their claims. Plaintiffs sufficiently alleged a concrete injury as to their fiduciary duty claim because UBH’s alleged violation presented a material risk of harm to plaintiffs’ interest in their contractual benefits. Plaintiffs also alleged a concrete injury as to the denial of benefits claim. Further, plaintiffs alleged a particularized injury as to both claims because UBH’s Level of Care Guidelines and Coverage Determination Guidelines for making medical necessity or coverage determinations materially affected each Plaintiff. And Plaintiffs’ alleged injuries were “fairly traceable” to UBH’s conduct. The panel held that the district court did not err in certifying the three classes to pursue the fiduciary duty claim, but the panel reversed the district court’s certification of the denial of benefits classes. The panel held that, on the merits, the district court erred to the extent it determined that the ERISA plans required the Guidelines to be coextensive with generally accepted standards of care. View "DAVID WIT, ET AL V. UNITED BEHAVIORAL HEALTH" on Justia Law

Plaintiffs brought this class action against the Plan’s administrator, AT&T Services, Inc., and the committee responsible for some of the Plan’s investment-related duties, the AT&T Benefit Plan Investment Committee (collectively, “AT&T”). Plaintiffs alleged that AT&T failed to investigate and evaluate all the compensation that the Plan’s recordkeeper, Fidelity Workplace Services, received from mutual funds through BrokerageLink, Fidelity’s brokerage account platform, and from Financial Engines Advisors, L.L.C. Plaintiffs alleged that (1) AT&T’s failure to consider this compensation rendered its contract with Fidelity a “prohibited transaction” under ERISA Section 406, (2) AT&T breached its fiduciary duty of prudence by failing to consider this compensation, and (3) AT&T breached its duty of candor by failing to disclose this compensation to the Department of Labor.   The Ninth Circuit affirmed in part and reversed in part the district court’s summary judgment in favor of Defendants. The panel reversed the district court’s grant of summary judgment on the prohibited transaction claim. Relying on the statutory text, regulatory text, and the Department of Labor’s Employee Benefits Security Administration’s explanation for a regulatory amendment, the panel held that the broad scope of Section 406 encompasses arm’s-length transactions. The panel held that the broad scope of § 406 encompasses arm’s-length transactions. Disagreeing with other circuits, the panel concluded that AT&T, by amending its contract with Fidelity to incorporate the services of BrokerageLink and Financial Engines, caused the Plan to engage in a prohibited transaction. The panel remanded for the district court to consider whether AT&T met the requirements for an exemption from the prohibited transaction bar. View "ROBERT BUGIELSKI, ET AL V. AT&T SERVICES, INC., ET AL" on Justia Law