King v. Blue Cross and Blue Shield, No. 15-55880 (9th Cir. 2017)
Annotate this CaseThe Ninth Circuit reversed the district court's grant of summary judgment to defendants in an action under the Employee Retirement Income Security Act (ERISA). Plaintiff alleged that defendants failed to adequately disclose that the lifetime benefit maximum applied to the plan at issue. The panel held that ERISA, as amended by the Affordable Care Act, does not ban lifetime benefit maximums for certain retiree-only plans; defendants violated ERISA's statutory and regulatory disclosure requirements by providing a faulty summary of material modifications describing changes to the lifetime benefit maximum in September 2010; and genuine disputes of material fact preclude summary judgment on the breach of fiduciary duty claims.
Court Description: Employee Retirement Income Security Act. The panel reversed the district court’s grant of summary judgment in favor of the defendants in an ERISA action regarding the denial of a welfare benefit plan participant’s claim for medical benefits on the basis of the plan’s lifetime benefit maximum. The panel held that ERISA, as amended by the Patient Protection and Affordable Care Act, does not ban lifetime benefit maximums for certain retiree-only plans. The panel held that the defendants violated ERISA’s statutory and regulatory disclosure requirements by providing a faulty summary of material modifications describing changes to the lifetime benefit maximum. The panel concluded that the summary did not reasonably apprise the average plan participant that the lifetime benefit maximum continued to apply to the retiree plan. The panel also held that genuine disputes of material fact precluded summary judgment on claims of breach of fiduciary duty in the failure to comply with ERISA’s disclosure requirements. The panel held that a defendant claims administrator was a fiduciary because it had authority KING V. BLUE CROSS AND BLUE SHIELD 3 to grant, deny, and review benefits claims, and there was a genuine dispute of material fact about whether this defendant misled the ERISA plan participant. The panel remanded the case to the district court.
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