East Coast Advanced Plastic Surgery, LLC v. Cigna Health & Life Ins. Co., No. 25-2204, __ F.4th __, 2026 WL 2751786 (2d Cir. Sept. 17, 2026) (Before Circuit Judges Leval and Park, and District Court Judge Jed S. Rakoff)

This week’s notable decision is yet another in a recent line of cases addressing the No Surprises Act (NSA), which was enacted by Congress in 2020 and took effect for benefit plan years beginning in 2022. The NSA effected changes to three parts of the U.S. Code: (1) ERISA, (2) the Internal Revenue Code (IRC), and (3) the Public Health Service Act (PHSA).

The purpose of the law is to protect patients from large, unexpected medical bills which they might receive after undergoing emergency care, or treatment by an out-of-network provider at an in-network facility. In disputes over payment for such treatment, the NSA essentially takes the patient out of the equation. It prohibits providers from balance-billing patients, i.e., billing the patient for the difference between the charged fee and the amount paid for by insurance. Instead, it forces providers and insurers to negotiate the dispute, and failing that, requires binding independent dispute resolution (IDR) arbitration.

Currently, neither insurers nor providers are happy with this arrangement. Insurers complain that IDR arbitrators rule in favor of providers too often and their awards are too high. Providers have a different complaint, discussed by the Second Circuit in today’s highlighted decision: although IDR awards are supposed to be “binding,” and “must be paid” within 30 days, many insurers simply refuse to comply.

Insurers can get away with this because when providers file lawsuits, the majority of federal courts have held that the NSA does not give providers a private right of action to enforce their IDR awards. In 2025, the Fifth Circuit confirmed this interpretation of the statute in Guardian Flight, L.L.C. v. Health Care Serv. Corp. (The Supreme Court declined to grant certiorari in January of this year.) Would the Second Circuit agree?

The plaintiff was East Coast Advanced Plastic Surgery, LLC (ECAPS), which performs breast reconstruction surgery for cancer patients who have undergone mastectomies. ECAPS was out of network with Cigna Health and Life Insurance Company, but it did have a contract with MultiPlan, Inc. (MPI), which assembles provider networks and sells access to insurers such as Cigna.

ECAPS’ contract with MPI obligated Cigna to pay ECAPS a “Contract Rate” equal to 85% of its billed charges for services to Cigna members. According to ECAPS, it “provided medical services to members of Cigna-administered plans but, in the ‘overwhelming majority’ of cases, Cigna paid ECAPS far less than the 85% Contract Rate.” ECAPS contends that it “invoked the IDR process and obtained IDR awards against Cigna in amounts exceeding $3 million,” but despite these awards, “Cigna has made no payments to ECAPS.” For its part, Cigna contends that “ECAPS engaged in fraudulent billing practices, causing Cigna to overpay by $8.5 million for certain ECAPS services.”

Both parties filed suit against each other, and the actions were consolidated. Cigna sued ECAPS under ERISA, the Declaratory Judgment Act, and Connecticut law for fraud, negligent misrepresentation, unjust enrichment, and conversion. Meanwhile, ECAPS sought a declaratory judgment that Cigna had violated its NSA obligation to pay the IDR determinations within 30 days, that Cigna owed ECAPS the full amount of those determinations, and that ECAPS was entitled to equitable and monetary relief.

The district court dismissed ECAPS’s complaint for failure to state a claim, holding that the NSA contains no express or implied private right of action to enforce IDR awards and that the Declaratory Judgment Act does not supply an independent cause of action to fill that gap. (Your ERISA Watch covered this ruling in our August 20, 2025 edition.) ECAPS appealed and this published decision from the Second Circuit was the result.

The appellate court began by noting that “Congress determines who may sue to enforce federal law,” and that when Congress does allow a private right of action to enforce its laws, “it usually does so expressly.” The Supreme Court has “strictly curtailed the authority of the courts to recognize implied rights of action”; such rights “are disfavored.”

Under those ground rules, the court examined the NSA to determine first whether its text “uses rights-creating language, meaning language that focuses on the individuals protected rather than the person regulated.” Second, it considered “whether the statute’s methods of enforcement manifest an intent to create a private remedy, as opposed to empowering agencies to enforce their regulations.”

The court found that while the NSA does have rights-creating language in the form of “shall pay” provisions, “that is not conclusive”: “it must also manifest an intent to provide for private enforcement.” The court emphasized that while the NSA incorporated the Federal Arbitration Act’s provision for vacating awards, it did not incorporate the FAA’s provision for confirming awards, unlike in other statutes. This omission “strongly suggests that Congress did not intend to create a private right of action to enforce IDR awards.”

The statutory scheme of the NSA also cut against a private right of action. The Second Circuit explained that the NSA has an “interlocking federal and state administrative scheme to enforce the NSA.” This scheme includes three federal agencies: the Department of Labor (under ERISA), the Treasury Department (under the IRC), and the Department of Health and Human Services (under the PHSA). These three agencies can sue or impose excise taxes on private employer-sponsored plans that violate the NSA and impose civil monetary penalties on non-compliant state and local governmental plans. States may also independently enforce the NSA against insurers.

According to the Second Circuit, this broad sweep of enforcement power “reflect[s] ‘Congress’s policy choice to enforce the [NSA] through administrative’ action, ‘not a private right of action.’” Quoting the Supreme Court, the court held that “[t]he express provision of one method of enforcing a substantive rule suggests that Congress intended to preclude others.”

The court quickly marched through each of ECAPS’s seven counterarguments and rejected them. First, ECAPS argued that the NSA does not expressly give the Labor or Treasury Departments enforcement power over private employer plans. However, the court found this irrelevant because “ERISA and the Internal Revenue Code, each of which the NSA amends, already authorize enforcement by those agencies.”

Second, ECAPS pointed to “minimal” efforts by the Department of Labor to enforce IDR awards. The court responded that “the relevant question is whether Congress authorizes agency enforcement, not how actively the agency exercises its authority.”

Third, ECAPS pointed to Treasury regulations that allow the department to waive enforcement, “[b]ut the fact that an agency may waive enforcement is not evidence of congressional intent to permit a private right of action.”

Fourth, ECAPS argued that Congress’ use of the term “binding” “is an[] indication of its intent to render them judicially enforceable by providers.” However, the Second Circuit stated that “this begs the question because the provision making the IDR determination ‘binding upon the parties involved’ says nothing about who may enforce it.”

Fifth, ECAPS attempted to draw analogies to the Tucker Act (which waives federal sovereign immunity for certain claims) and civil rights case law under 42 U.S.C. § 1983. The Second Circuit found both inapposite. It explained that Tucker Act cases turn on sovereign immunity and a “money-mandating inquiry,” which was not present here, and § 1983 plaintiffs “do not have the burden of showing an intent to create a private remedy because § 1983 generally supplies a remedy for the vindication of rights secured by federal statutes.”

Sixth, ECAPS contended that refusing to allow a private right of action “would ‘render the incorporation of section 10 [regarding vacatur] of the FAA superfluous and absurd.’” It argued there was no point in letting a losing party seek vacatur if no one could be forced to pay in the first place. The court disagreed, suggesting that both plans and providers might have incentives to seek vacatur in various circumstances.

Seventh, ECAPS argued that denying a private remedy “renders meaningless the entirety of the statutory IDR regime.” The court rejected this too, quoting the Fifth Circuit in Guardian Flight: “Agencies may enforce the IDR process, so the absence of a private right of action would not undermine the process. ‘Congress may have judged it better to have an administrative enforcement mechanism handle most award disputes instead of throwing open the floodgates of litigation.’”

Finally, having concluded that the NSA provides no implied cause of action, the court made quick work of ECAPS’s fallback theory that the Declaratory Judgment Act could independently support relief. The Second Circuit agreed with the district court that the Act “does not create an independent cause of action.”

As a result, the Second Circuit affirmed in full the dismissal of ECAPS’s complaint, dealing a blow to providers seeking judicial enforcement of their IDR awards. Now that two appellate courts have reached the same conclusion, it seems likely that enforcement pressure will shift back to the government. While the current dysfunctional Congress is one of the least productive in history, the relevant regulatory agencies have been active recently, issuing a final rule in June to overhaul the IDR process. Disputes over the NSA are likely to continue, however, and we will do our best to keep you updated on any relevant decisions.

Below is a summary of this past week’s notable ERISA decisions by subject matter and jurisdiction.

Arbitration

Fourth Circuit

Wadood v. AT&T Technical Services Co., Inc., No. 1:25-cv-1512 (RDA/LRV), 2026 WL 2790270 (E.D. Va. Sept. 17, 2026) (Judge Rossie D. Alston, Jr.). Tameem Wadood, proceeding pro se, sued his former employer, AT&T Technical Services Co., Inc., alleging that after he was questioned by supervisors about his religion and national origin in 2023, he experienced disparate treatment, reassignment, exclusion from projects, downgraded evaluations, and eventual termination in 2025, with retaliation escalating after he filed human resources complaints in 2024. His operative complaint asserted claims for discrimination, retaliation, age discrimination, defamation, and interference with prospective employment. Wadood’s original complaint did not assert an ERISA claim. AT&T moved to compel arbitration, relying on a “Management Arbitration Agreement” (MAA) that Wadood had electronically signed as part of the company’s onboarding process. The MAA had carve-outs for certain claims, including ERISA claims. Wadood opposed AT&T’s motion and separately moved for leave to file an amended complaint, which would include a new claim under ERISA § 510. This claim alleged that “(i) he participated in Defendant’s 401(k) plan; (ii) he made contributions; (iii) ‘AT&T engaged in adverse actions timed to interfere with Plaintiffs attainment of benefits’; (iv) he was the subject of ‘[f]orced transfers, biased evaluations, and retaliatory documentation occurred near vesting milestones’; (v) Defendant failed to provide ‘accurate information regarding Plaintiffs retirement benefits upon separation’; and (vi) Defendant ‘acted with specific intent to interfere with his ERISA-protected benefits.’” AT&T opposed the motion, and the court resolved the motions from both sides in this order. The court quickly concluded that the MAA was a valid and enforceable contract under Virginia law, that it was not a contract of adhesion, that Wadood’s electronic signature bound him, and that the MAA’s broad arbitration clause covered all of the claims pleaded in the operative complaint. The court then turned to Wadood’s proposed amended complaint. First, the court found the proposed claim was based on facts that “were in his possession and are not newly discovered.” Furthermore, the amendment’s timing showed that it was calculated to manufacture an exception to arbitration: “Courts reject amendment where there is a purpose of avoiding arbitration.” Second, the court held that Wadood’s proposed § 510 claim was not plausible. His allegations that adverse employment actions were “timed to interfere” with his benefits and that AT&T acted with “specific intent” to interfere with his benefits were “vague and conclusory” and “not sufficient to meet Plaintiff’s burden” under the Supreme Court’s Twombly/Iqbal rules. The court thus denied Wadood’s motion for leave to amend and granted AT&T’s motion to compel arbitration, directing the parties to arbitrate under the MAA and staying the case pending the arbitrator’s decision. (In a footnote, the court apologized for the delay in its ruling, noting that “this Division has been inundated with hundreds of habeas applications each of which requires expeditious review and each of which involves an individual in custody who desires release. Indeed, to date, more than 3,000 civil cases have been filed in the Alexandria Division alone.”)

Breach of Fiduciary Duty

Eighth Circuit

O’Donnell v. Charter Communications, Inc., No. 4:25-CV-157-ZMB, 2026 WL 2694267 (E.D. Mo. Sept. 14, 2026) (Judge Zachary M. Bluestone). Telecom giant Charter Communications, Inc. sponsors a 401(k) Savings Plan funded by employee and employer contributions. The employee contributions vest immediately, but Charter’s matching contributions only vest after several years of service. When a participant leaves Charter before its matching contributions vest, the unvested contributions revert to a plan forfeiture account. From 2017 through 2024, the plan directed that “Assets in Accounts which are forfeited shall be used to pay Plan administrative expenses [before] reduc[ing] the Employer Contributions.” Despite that language, Charter instead prioritized the use of forfeited assets to offset its own matching contributions, using $189.5 million to reduce its contributions between 2020 and 2024 while plan participants were charged $40.9 million in administrative expenses. (In 2025, after this suit was filed, Charter amended the plan to permit forfeitures to offset employer contributions ahead of administrative expenses.) A group of former Charter employees and plan participants brought this putative class action on behalf of the plan to challenge Charter’s use of plan forfeitures. After consolidating two related suits and appointing interim class counsel, the case is finally at issue. Before the court was a complaint with six counts: three theories of breach of fiduciary duty, a violation of ERISA’s anti-inurement provision, and two prohibited transaction claims. The defendants are Charter as well as individual defendants Carolyn Wood and Paul Weber, who were identified as plan administrators. Defendants moved to dismiss for failure to state a claim. The court first dismissed the claims against the individual defendants without prejudice, holding that plaintiffs failed to allege any specific conduct, or even awareness, by Wood or Weber regarding the handling of forfeitures. Turning to the fiduciary duty claims against Charter, the court rejected Charter’s argument that they were a disguised denial-of-benefits action requiring administrative exhaustion. The court found that plaintiffs were not seeking individual benefits but instead sought plan-wide equitable relief under 29 U.S.C. § 1132(a)(3). On the merits, the court found that the plan unambiguously required forfeited assets to be applied to administrative expenses before offsetting Charter’s matching contributions, and that Charter’s contrary practice plausibly constituted a fiduciary breach of duty to act in accordance with the documents governing the plan. (The court reserved for later whether specific fees at issue, such as individual investment expenses, qualified as “administrative expenses” under the plan.) The court also allowed plaintiffs to proceed with their claims for breach of the duties of loyalty and prudence. It distinguished other cases dismissing forfeiture claims on the ground that the plans in those cases, unlike Charter’s, “either required or gave discretion to apply forfeitures to offset employer contributions in the first instance.” The court also rejected Charter’s argument that any resulting loss to the Plan was speculative, concluding that a shortfall in plan assets was a straightforward, non-speculative consequence of misapplying the forfeitures. The court reached a different result on plaintiffs’ anti-inurement and prohibited transaction claims, holding both failed “because Plaintiffs do not allege that the forfeited assets ever left the Plan.” The court acknowledged that some case law supported plaintiffs, but “the vast majority of courts to consider this issue have reached the opposite conclusion, at least where no assets have left the plan.” The court further held that the intra-plan reallocation of forfeitures did not constitute a “transaction” with a party in interest or a fiduciary under 29 U.S.C. § 1106, noting that if it were to accept plaintiffs’ theory, “any intra-plan transfer of funds to offset employer contributions – even if expressly permitted in a plan” would result in a prohibited transaction. The court thus granted in part and denied in part the motion to dismiss, and the case will continue.

Ninth Circuit

Perez v. Liberty Mutual Group, Inc., No. 25-cv-08775-HSG, 2026 WL 2724923 (N.D. Cal. Sept. 15, 2026) (Judge Haywood S. Gilliam, Jr.). Lester Anthony Perez was a participant in the Liberty Mutual 401K Plan, a defined-contribution individual account plan sponsored by Liberty Mutual Group, Inc. and administered through the Liberty Mutual Retirement Committee. The plan is funded by employee contributions, which vest immediately, and employer contributions, which vest 50 percent after one year of service and fully after two years. Unvested employer contributions are forfeited when a participant has a break in service before vesting. Perez alleges that from 2020-24 Liberty and the Committee used forfeited employer contributions to offset their future contributions to the plan, rather than using them to help pay plan expenses for the benefit of plan participants. Perez filed this putative class action against Liberty and the Committee, asserting claims for breach of fiduciary duty, violation of ERISA’s anti-inurement provision, violation of ERISA’s prohibited transaction provision, and failure to monitor fiduciaries. Defendants moved to dismiss for failure to state a claim. The court included the plan document in its consideration because Perez’s claims relied on its terms and its authenticity was undisputed. The court dismissed the breach of fiduciary duty claim for two reasons. First, the court explained that a breach of fiduciary duty can only occur if there is an exercise of discretionary authority or control, but Section 5.1 of the plan required forfeited employer contributions to be used for future contributions: “Application of Forfeitures. All forfeitures shall be applied towards satisfying the amount of the Company Contributions for the Plan Year for which such amounts are forfeited, and for subsequent Plan Years until exhausted” (emphasis added). As a result, defendants had no discretion over how to allocate the forfeitures and thus there could be no breach of fiduciary duty. Second, the court held that even if defendants’ conduct was fiduciary in nature, Perez failed to allege that their use of the forfeitures violated any plan term or deprived him of any promised benefit. The court agreed with other courts holding that “‘ERISA does no more than protect the benefits which are due to an employee under a plan’… It ‘does not create an exclusive duty to maximize pecuniary benefits.’” The court also dismissed Perez’s anti-inurement and prohibited transaction claims. The court reasoned that because the forfeited contributions remained plan assets before and after being redirected, defendants’ “incidental benefit” from reduced funding obligations did not cause plan assets to inure to their benefit. As for the prohibited transaction claim, the court held that ERISA targets arm’s-length dealings with plan insiders that risk underfunding a plan, not an intra-plan reallocation mandated by the plan’s own terms. Finally, the failure-to-monitor claim failed because Perez identified no person or entity to whom defendants had delegated fiduciary responsibility, and because it was derivative of the fiduciary duty claim the court had already rejected. As a result, the court granted defendants’ motion to dismiss in full. The court noted that it was “skeptical that Plaintiff can cure the defects discussed above” because Perez’s theory “appears to fail as a matter of law,” but it chose to dismiss without prejudice.

Class Actions

D.C. Circuit

Whetstone v. Howard Univ., No. 23-2409 (LLA), 2026 WL 2797972 (D.D.C. Sept. 18, 2026) (Judge Loren L. AliKhan). Howard University established a defined benefit retirement plan in 1976. The plan’s default form of benefit is a single life annuity (SLA), but married participants typically receive a joint and survivor annuity (JSA). Under ERISA Section 205(d), a qualified JSA must be the “actuarial equivalent” of the SLA. To perform the conversion from an SLA to a JSA, the plan uses the 1984 Unisex Pension Mortality Table and a 7% interest rate. Stephen G. Whetstone, a retired plan participant who elected a JSA, contends that these actuarial assumptions were “antiquated” and understated his true benefit. Applying the Treasury Department’s preferred assumptions instead, he contends he should be receiving $17.99 more per month in benefits. Whetstone filed this putative class action in which he asserted three claims against Howard and its Retirement Plan Committee: (1) violation of the JSA actuarial equivalence requirement under 29 U.S.C. § 1055(d); (2) violation of ERISA’s definitely determinable benefit rule under 29 U.S.C. § 1102(b)(4); and (3) breach of fiduciary duty under 29 U.S.C. § 1104(a)(1). In 2024, the court granted defendants’ motion to dismiss in part, dismissing Count 2 as time-barred but allowing Counts 1 and 3 to proceed. (Your ERISA Watch covered this ruling in our September 18, 2024 edition.) The case was referred to a magistrate judge for mediation, and in May of 2025 the parties reached a settlement. The parties then negotiated an agreement, followed by Whetstone filing an unopposed motion for leave to file a second amended complaint, for preliminary class certification, for preliminary approval of the parties’ proposed $1.3 million settlement, and for approval of the form and method of notice to class members. In this order the court began by granting leave to file the second amended complaint, which added Linda Hutchins as a named plaintiff representing a second subgroup and conformed the class period and claims to the settlement. Applying Federal Rule of Civil Procedure 23(a), the court found numerosity satisfied by the roughly 1,788-member class, commonality satisfied because all class members were subject to the same actuarial assumptions and conversion methodology, typicality satisfied because Whetstone and Hutchins each represent one of the settlement’s two subgroups and their claims arise from the same allegedly unlawful methodology, and adequacy satisfied given the named plaintiffs’ active participation in the litigation and class counsel’s experience in complex ERISA class actions. The court further held that the class satisfied Rule 23(b)(1) because under subsection (A) individual suits by more than 1,700 class members risked inconsistent adjudications imposing incompatible standards of conduct on defendants, and under subsection (B), individual adjudications concerning plan-wide actuarial methodology would be dispositive of other class members’ interests. Turning to preliminary approval under Rule 23(e), the court explained that the settlement would allocate 75% of the net settlement to Subgroup A (class members with annuity start dates after August 17, 2017), distributed pro rata by each member’s calculated underpayment, and 25% to Subgroup B (class members with earlier start dates) distributed by current benefit size. The settlement also involved monthly benefit increases, retroactive lump-sum payments, requested attorney’s fees of up to one-third of the settlement fund, and $5,000 case contribution awards for each named plaintiff. The court found the settlement was the product of arm’s-length negotiation, noting three years of litigation, a contested motion to dismiss, discovery, mediation before the magistrate judge, and continued negotiation over expert analyses and participant data. The court noted that actuarial equivalence is a “largely unsettled” area of ERISA, citing the Sixth Circuit’s decision earlier this year in Reichert v. Kellogg Co., and that trial would likely require a “costly ‘battle of the experts’” over “highly technical” issues. The court found the settlement’s estimated recovery rates of approximately 30.8% for Subgroup A and 18.2% for Subgroup B were consistent with comparable ERISA actuarial equivalence settlements, including the 17% recovery approved in January of this year in Franklin v. Duke University. The court also found the litigation sufficiently developed for informed settlement, deferred assessment of the class’ reaction pending notice, and credited the shared view of experienced counsel on both sides that the settlement was fair and reasonable. As a result, the court granted Whetstone’s unopposed motion in full. The court directed the settlement administrator to send a class notice and asked the parties to propose dates for a final fairness hearing on or after December 18, 2026.

Disability Benefit Claims

First Circuit

Germana v. Hartford Life and Accident Insurance Co., No. 23-30065-MGM, 2026 WL 2823567 (D. Mass. Sept. 21, 2026) (Judge Mark G. Mastroianni). Scott A. Germana worked as a registered nurse for Trinity Health Corporation, which provided long-term disability benefits to its employees under a policy issued and administered by Hartford Life and Accident Insurance Company. Germana stopped working in 2018 at age 54, reporting abdominal pain and later spine-related conditions including thoracic and lumbar spondylosis. The policy defined disability as the inability to perform one’s own occupation during an elimination period and the following 24 months, followed by inability to perform “Any Occupation” thereafter. Hartford approved Germana’s claim in 2019 after an independent physician found he retained substantial functional capacity but nonetheless supported some restrictions, and it later obtained a labor market survey identifying multiple sedentary occupations Germana could perform once the Any Occupation standard took effect in October 2020. When Germana’s treating pain-management physician did not respond to requests for updated records, Hartford terminated Germana’s benefits for failure to furnish proof of loss, then reinstated benefits under a reservation of rights after receiving new records and an attending physician statement from Germana’s primary care physician. Hartford referred Germana’s file to an independent orthopedic surgeon who, after reviewing the record and speaking with Germana’s primary care physician, opined that Germana could perform sedentary work full-time with specified restrictions on sitting, standing, walking, lifting, and driving. Based on that opinion and a vocational employability analysis identifying suitable sedentary occupations, Hartford terminated Germana’s LTD benefits in 2021. Germana appealed, submitting additional medical records and a reference to a Social Security disability award without the underlying decision. Hartford referred the appeal to independent gastroenterology and pain-medicine physicians, both of whom found no objective support for functional restrictions, and upheld the denial in 2022. Nine months later, Germana’s counsel submitted a psychiatric evaluation, which Hartford declined to consider as untimely and outside the administrative record. (A magistrate judge later struck references to that report from the summary judgment record, along with Germana’s argument that Hartford’s reviewing physicians engaged in the unlicensed practice of medicine by evaluating his file without a Massachusetts license. Your ERISA Watch covered that ruling in our July 24, 2024 edition.) Germana then brought this action under 29 U.S.C. § 1132(a)(1)(B), and the parties filed cross-motions for summary judgment. Because the policy vested Hartford with discretionary authority, the court applied the arbitrary and capricious standard of review. Addressing Germana’s argument that Hartford’s denial letter failed to adequately explain what he needed to submit on appeal, the court held the letter satisfied ERISA’s notice requirements under 29 U.S.C. § 1133(1) and 29 C.F.R. § 2560.503-1(g)(1)(iii), explaining that the regulation requires a plan to help a claimant “perfect,” not necessarily “win,” an appeal. According to the court, the letter identified the specific restrictions found on peer review, the sample occupations identified, and Germana’s right to submit additional records including Social Security materials. The court likewise rejected Germana’s “post-hoc rationalization” argument, finding that Hartford consistently relied on the same Any Occupation, lack-of-restriction rationale throughout the administrative process and litigation, rather than shifting to an entirely new basis for denial. The court also rejected Germana’s challenges to the merits of Hartford’s decision. It found no inconsistency between Dr. Morgenstein’s driving and sitting restrictions, reasoning that driving and desk-sitting do not allow for similar repositioning and thus are “very different experiences.” Furthermore, none of the identified Any Occupation positions required driving. It also held that Hartford did not abuse its discretion in declining to fully credit Germana’s subjective reports of pain and medication side effects, noting that requiring objective support for functional limitations is permissible. The record, including Germana’s own denials of medication side effects and his primary care physician’s view that he could perform sedentary work, further supported Hartford’s conclusion. The court upheld the magistrate’s prior exclusion of the post-appeal psychiatric evaluation because it was outside the administrative record’s temporal cutoff, as well as the rejection of Germana’s unlicensed-practice-of-medicine argument, agreeing with the magistrate that federal regulations do not require reviewing physicians to be licensed in the claimant’s state of residence, and that Massachusetts’s definition of the practice of medicine did not clearly extend to file-review evaluations. Finally, the court found no procedural unreasonableness or improper influence from Hartford’s structural conflict, crediting Hartford’s use of independent third-party vendors, continued payment of benefits under a reservation of rights, use of a separate appeals unit, and extensions granted to Germana’s counsel as active steps that diminished the weight of the conflict. As a result, the court granted Hartford’s motion for summary judgment, denied Germana’s, and entered judgment for Hartford.

Second Circuit

Schuyler v. Sun Life Assurance Co. of Canada, No. 20-CV-10905 (RA), 2026 WL 2823712 (S.D.N.Y. Sept. 18, 2026) (Judge Ronnie Abrams). Kristen Schuyler worked as a sales representative for Benco Dental beginning in 2011, a role that required extensive driving as well as air travel, conference attendance, and administrative work. In 2015, Schuyler suffered a severe traumatic brain injury after falling down a flight of stairs during a weekend trip, suffering bleeding in her brain, a skull fracture, and other injuries that required emergency hospitalization and extensive follow-up care. Although Schuyler continued working at Benco for nearly four more years, and her earnings improved during that period, her symptoms, which included cognitive and memory deficits confirmed by neuroimaging, worsened over time. In 2019, she was eventually forced to stop working. Schuyler submitted a claim under Benco’s ERISA-governed long-term disability benefit plan to the plan’s insurer, Sun Life Assurance Company of Canada. Sun Life denied Schuyler’s claim, as well as her appeal, contending that she had not shown an inability to perform the duties of her “Regular Occupation.” (This meant that Sun Life never reached the question of whether Schuyler was disabled after 24 months, which required disability from “Any Occupation.”) While her claim was pending, Schuyler applied for and was awarded Social Security disability benefits based on two 2022 evaluations diagnosing mild neurocognitive disorder and significant neurocognitive deficits. This evidence post-dated the administrative record and thus Sun Life did not consider it when it denied Schuyler’s claim. Schuyler filed this action in 2020, but the case was not initially decided on the merits. Instead, the district court ruled for Sun Life on the ground that Schuyler had waived her right to sue as part of a separation agreement with Benco. On appeal the Second Circuit reversed this ruling, holding that Schuyler did not knowingly and voluntarily release her ERISA claims. (This decision was Your ERISA Watch’s case of the week in our August 20, 2025 edition. Disclosure: Kantor & Kantor represented Ms. Schuyler in that appeal.) On remand, the parties renewed their cross-motions for summary judgment, which the court resolved in this ruling. The court first addressed which standard of review governed Sun Life’s denial. Although the plan’s grant of discretionary authority would ordinarily trigger arbitrary and capricious review, the court found that Sun Life forfeited any deference by violating ERISA’s claims-procedure regulation, 29 C.F.R. § 2560.503-1. Specifically, the court observed that in its initial review, Sun Life’s vocational expert, Timothy Andenmatten, classified Schuyler’s occupation as requiring standing or walking “to a significant degree,” or six hours in an eight-hour day, consistent with the regulatory definition of “light work.” On appeal, however, a second Sun Life vocational expert, Julie Finnegan, reclassified the same occupation as requiring only “occasional” standing and walking, or roughly two-and-a-half hours per day, which was equivalent to “sedentary work.” Sun Life’s appeal denial letter “appears to acknowledge that the two occupational analyses reached different conclusions as to the role’s standing and walking requirements, but nowhere explains why Sun Life credited Finnegan’s assessment over Andenmatten’s.” This error “was not harmless as it may well have had a substantial impact on the viability of Schuyler’s ‘Regular Occupation’ disability claim,” and “Schuyler had no opportunity to respond.” The court thus applied de novo review, and under that standard the court found the record presented material factual disputes, including conflicting evidence on the extent of Schuyler’s functional limitations and her credibility, that precluded summary judgment for either side. Although the parties had stipulated that the court could resolve disputed facts by conducting a “bench trial on the papers,” the court noted that “both parties acknowledged at oral argument…[that] the Court need not conduct such a procedure and may instead remand the claim to the plan administrator for a renewed determination in view of the full record.” Given the procedural violation, the incomplete record, and significant new evidence that had never been before Sun Life, including Schuyler’s favorable Social Security disability determination and the underlying expert evaluations, Sun Life’s evidence of Schuyler’s subsequent work as a real estate agent, and a disputed nurse consultant report Schuyler claimed was never properly disclosed to her, the court determined that “remand to Sun Life is the appropriate course of action.” The court also noted that remand would allow Sun Life to reach the Any Occupation disability question it had never addressed. The court thus denied both cross-motions for summary judgment and stayed the case pending Sun Life’s decision on remand.

Sixth Circuit

DiGeronimo v. Unum Life Ins. Co. of America, No. 1:22-cv-00773, 2026 WL 2718210 (N.D. Ohio Sept. 14, 2026) (Judge David A. Ruiz). Donald DiGeronimo worked for Independence Excavating, Inc. for nineteen years, eventually acquiring the awesome title of “Vice President of Demolition.” DiGeronimo was covered under two long-term disability policies: a Unum Life Insurance Company of America policy for officers, directors, and senior managers, and a Provident Life and Accident Insurance Company policy for employees. (Unum acquired Provident in 1999.) Earlier in this litigation, the parties disputed whether the Unum policy was governed by ERISA; in September of 2023 the court held that it was because it did not meet the Department of Labor’s “safe harbor” requirements. (Your ERISA Watch covered this decision in our October 4, 2023 edition.) DiGeronimo had a decades-long history of temporal lobe epilepsy, including two lobectomies, and continued to experience primarily nocturnal seizures that he and his longtime treating neurologist, Dr Nancy Foldvary-Schaefer, attributed to stress and sleep deprivation, which resulted in daytime cognitive impairment. He applied for long-term disability benefits in July 2020, alleging an onset date of June 5, 2020, citing an inability to stay alert or maintain the cognitive sharpness his job required. Unum’s reviewing consultants found that the contemporaneous medical record, which included stable brain MRIs, unremarkable neurological examinations, and a Karnofsky Performance Status score of 90, did not support functional impairment precluding full-time work. Unum thus denied the claim in November of 2020. DiGeronimo appealed with a letter from Dr. Foldvary-Schaefer, a vocational report from Kathleen Reis, and additional medical records, but Unum again concluded the evidence did not support his claimed restrictions, and Unum denied the appeal in March 2022. DiGeronimo sued under 29 U.S.C. § 1132(a)(1)(B) to recover benefits under both the Unum and Provident policies. After the court denied DiGeronimo’s request for discovery regarding Unum’s medical reviewers and their denial rates (an order covered in our September 3, 2025 edition), the parties filed cross-motions for judgment. Because both plans vested Unum with discretionary authority to determine eligibility, the court applied the Sixth Circuit’s two-part framework which asks whether the administrator “engaged in reasoned decisionmaking” and whether the ultimate decision was “supported by substantial evidence in the administrative record.” Addressing DiGeronimo’s procedural challenges, the court found that Dr. Foldvary-Schaefer’s successive opinions were either conclusory or unexplained, and that Unum’s response “more than adequately” answered those opinions by pointing to unremarkable examinations, stable imaging, and DiGeronimo’s Karnofsky score. The court rejected DiGeronimo’s argument that Unum engaged in “cherry-picking,” finding that DiGeronimo did not identify material evidence that Unum overlooked, and that Unum offered a reasoned explanation for crediting its reviewers over Dr. Foldvary-Schaefer. The court likewise found no procedural defect in Unum’s treatment of Reis’s vocational opinions, as her disability conclusion was predicated on Dr. Foldvary-Schaefer’s restrictions. Turning to DiGeronimo’s structural conflict argument, the court acknowledged that Unum’s dual role as administrator and payor created an inherent conflict but explained that such a conflict warrants weight only where a claimant shows it “materialized in a concrete way” to influence the decision. The court rejected as conclusory DiGeronimo’s arguments regarding Unum’s denials in other cases, and disagreed that Unum was required to conduct an in-person examination, especially because DiGeronimo’s treating neuro-oncologist had examined him in person after the alleged onset date and found him neurologically intact. Finally, the court rejected DiGeronimo’s contentions that Unum was obligated to produce its reviewers’ curriculum vitae and that its reviewers lacked adequate qualifications. The court reiterated its earlier discovery ruling that the CVs were not part of the administrative record because they were not relied upon in making the benefit determination, and explained that ERISA does not require administrators to retain “the narrowest of specialists,” particularly where a board-certified neurologist had independently reviewed DiGeronimo’s file. The court thus granted defendants’ motion for judgment on the administrative record and denied DiGeronimo’s cross-motion.

Ninth Circuit

Bachand v. Reliance Standard Life Ins. Co., No. 25-cv-02061-MMC, 2026 WL 2723471 (N.D. Cal. Sept. 15, 2026) (Judge Maxine M. Chesney). Anna Bachand was a research and development engineer for Medtronic, Inc. and a participant in Medtronic’s ERISA-governed group long-term disability benefit plan, which was insured by Reliance Standard Life Insurance Company. In 2022, at the age of 27, Bachand was hospitalized and diagnosed with acute autoimmune hepatitis, for which she was prescribed prednisone and later the immunosuppressant Myfortic. Bachand was treated in part by immunologist Dr. Sam Ahn. She stopped working in May of 2022 and filed a claim for benefits under the plan. After a “major flare” in her condition in May 2023, Reliance approved Bachand’s claim and began paying benefits retroactive to her first day of eligibility. By early 2024, however, Bachand’s liver enzyme levels had stabilized, she had been weaned entirely off prednisone, and her treating physicians described her as “doing well.” Relying on this improvement, Reliance informed Bachand in April of 2024 that it believed she was capable of sedentary work and terminated further benefits. Bachand appealed, submitting evidence that she continued to experience fatigue, tinnitus, and other symptoms that she and Dr. Ahn attributed to the long-term side effects of Myfortic rather than to active liver disease. Reliance retained an independent physician, Dr. Christian Jackson, to review the file; after repeated unanswered attempts to reach Dr. Ahn by phone, Dr. Jackson concluded the medical records did not document restrictions or limitations attributable to Bachand’s condition or its treatment. Reliance thus denied Bachand’s appeal, and after considering supplemental submissions from Dr. Ahn, issued a final denial in November of 2024. Bachand filed this action under ERISA § 502(a)(1)(B) and the parties stipulated to de novo review. The case was tried to the court on cross-motions for judgment under Federal Rule of Civil Procedure 52. As a threshold matter, the court addressed Bachand’s request to supplement the administrative record with three of Dr. Ahn’s clinical summaries that Reliance did not have when it denied her appeal. The court admitted the two summaries that predated the close of the administrative appeal, concluding that they were needed to evaluate the weight of Dr. Ahn’s later opinions and Bachand’s self-reported symptoms, but excluded the third, which post-dated the appeal period. Turning to the merits, the court found that while “Reliance’s relatively succinct explanation for its decision is by no means an exemplar for others to follow, it has satisfied ERISA’s requirement that it provide a ‘specific’ reason for its decision, namely, that Bachand’s medical records did not support a finding of total disability.” That decision involved “an implicit rejection of Dr. Ahn’s and Bachand’s statements that her symptoms were so severe as to prevent full-time work[.]” The court agreed with Reliance, finding that Dr. Ahn’s treatment notes through mid-2024 repeatedly described Bachand as improving, with only vague references to “some fatigue and muscle aches.” The court further found that Dr. Ahn’s newly-admitted September 2024 letter and October 2024 questionnaire – which first attributed Bachand’s limitations to Myfortic’s side effects – introduced numerous symptoms, including dizziness, headaches, and racing heartbeat, that did not appear in his contemporaneous records. The court also noted that Dr. Ahn’s repeated failure to return Dr. Jackson’s calls undercut the reliability of his after-the-fact opinion. The court stated that Reliance’s vocational specialist had identified sedentary occupations, including biomedical engineer, for which Bachand remained qualified. The court acknowledged Bachand’s personal account of her difficulties, but was unpersuaded “for essentially the same reasons as set forth with respect to Dr. Ahn’s opinions, namely, an absence in her medical records of either her reporting or a physician’s recording of any symptom being of such severity as to support a finding she was unable to perform suitable work[.]” The court explained that it was “sympathetic to Bachand’s predicament and what will surely be a difficult, life-long battle to keep the symptoms of her condition at bay and maintain a healthy life.” However, the court was “constrained by the record before it, and, on those facts, Bachand has not carried her burden to show she is Totally Disabled.” As a result, Reliance’s motion for judgment was granted and Bachand’s was denied.

Syed v. Unum Life Ins. Co. of Am., No. CV 25-01052-MWF (CTSx), 2026 WL 2807048 (C.D. Cal. Sept. 18, 2026) (Judge Michael W. Fitzgerald). Maha Syed, a corporate associate attorney at Cooley LLP, was covered by Cooley’s ERISA-governed long-term disability plan, which was insured by Unum Life Insurance Company of America. Beginning in 2023, Syed reported a constellation of symptoms, including nausea, dizziness, racing heart, difficulty concentrating, low mood, and anxiety, which she attributed to major depressive disorder and generalized anxiety disorder diagnosed by her therapist. She took a leave of absence from Cooley in May of 2023 and submitted a claim to Unum in August. After reviewing an attending physician statement, treatment records, and a call with Syed describing her symptoms, Unum approved her claim in October. Soon after, Syed’s psychiatric nurse practitioner began reporting improving symptoms and normal mental status examinations, a trend that continued into early 2024 alongside reports that her depression and anxiety were “stable and manageable.” Around that time, Syed also began cardiology evaluation for possible dysautonomia, though an initial stress test was inconclusive. In early 2024, Unum referred Syed’s file to two reviewing psychiatrists, who concluded that medical records did not support continued work-preclusive impairment. Unum thus terminated Syed’s benefits effective April 12, 2024. Syed appealed, submitting a new independent evaluation from a neurologist who diagnosed her, based on telehealth examination   and a tilt table test, with postural orthostatic tachycardia syndrome (“POTS”) and chronic fatigue syndrome, along with supporting opinions from her cardiologist, primary care physician, and mental health providers, and narrative statements from herself, her sister, and a friend. After two further physician reviewers again concluded the record did not support disability, Unum upheld its denial. This action followed and proceeded to cross-motions for judgment under Federal Rule of Civil Procedure 52. The parties stipulated to de novo review. As a threshold matter, the court denied Syed’s motion to exclude defense arguments she characterized as improper post hoc rationales under the Ninth Circuit’s decision in Collier v. Lincoln Life Assurance Co. of Boston. (That case, in which the plaintiff was represented by Kantor & Kantor, ruled that “a district court ‘clearly errs by adopting a newly presented rationale’ when reviewing a denial of benefits that the insurer did not raise during its administrative processes.”) The court stated that “[t]he arguments and evidence on which the Court relies – as discussed below, the lack of substantiated functional restrictions, the largely unremarkable test results, the documented improvement in psychological symptoms, and the degree to which Plaintiff’s later opinions depend on subjective reports – were either identified explicitly in Defendant’s denial letters or are fairly considered subsidiary to the same rationales so identified.” As a result, they were not “new” within the meaning of Collier. On the merits, the court found the medical evidence closest in time to the benefit termination to be most persuasive, and that this contemporaneous record reflected a predominantly behavioral impairment that was stabilizing and improving by early 2024. Early complaints of nausea were attributed to medication side effects rather than an independent physical condition. The court found that Syed’s treating providers’ later opinions were unsupported by their own contemporaneous clinical findings. Her nurse practitioner’s mental status examinations undercut her later opinion that Syed could not work, and her therapist offered no functional assessment corroborating a work-preclusive condition. The court likewise gave limited weight to Syed’s later dysautonomia- and POTS-based theory of disability, explaining that a diagnosis alone does not establish disability. Furthermore, Syed’s neurologist’s opinion was undermined by underlying tilt table results “at the upper limit of normal,” and “there is no indication that he reviewed or considered the contemporaneous evidence…which suggested that Plaintiff’s medical leave was the result of a particular mental health episode.” Syed’s cardiologist’s opinion suffered from similar issues. The court also declined to credit Syed’s lay narrative statements as sufficient, standing alone, to establish functional impairment, noting that they must be “weighed against a medical record of unremarkable exam results and a lack of specific medical observations.” The court also rejected Syed’s argument that Unum’s reviewers’ references to “Plaintiff’s potential ability to work a less demanding job than corporate practice at Cooley” undermined the denial. The court found that the Policy’s “usual occupation” standard turned on the substantial and material acts she performed at Cooley, not her capacity for other work, and “the record does not establish by a preponderance of the evidence” that she was disabled from her position at Cooley. The court thus affirmed Unum’s termination of Syed’s benefits and entered judgment in Unum’s favor.

Zayn v. Unum Life Ins. Co. of America, No. 3:25-cv-01190-JR, 2026 WL 2719813 (D. Or. Sept. 15, 2026) (Magistrate Judge Jolie A. Russo). Nur Zayn worked as a product manager for CVS Health and was a participant in CVS Health’s ERISA-governed long-term disability benefit plan, which was administered by Unum Life Insurance Company of America. In October of 2019, when she was 37, Zayn was diagnosed with Young-Onset Parkinson’s Disease and began treatment with neurologist Dr. Elise Anderson. Over the following two years Zayn continued working while experiencing progressively worsening tremor, rigidity, brain fog, and difficulty with word-finding and multitasking, which she and Dr. Anderson attributed to her disease. Zayn stopped working in June of 2021 and submitted a claim to Unum for benefits. Unum approved Zayn’s claim under the plan’s “own-occupation” definition of disability, which after 24 months shifted to require her to be unable to perform “any gainful occupation” for which she was reasonably fitted by education, training, or experience. The Social Security Administration separately found Zayn disabled as of November 1, 2022. Unum continued paying benefits through mid-2024, including a July 2024 determination that improvement was “not expected.” However, after discovering that Zayn maintained an Instagram account and website promoting a small astrology-reading side business, and obtaining surveillance footage showing her performing brief yard work, Unum denied her claim after referring the file for review by several consulting physicians. Two of these physicians mistakenly relied on information drawn from another claimant’s file. On appeal, Zayn provided statements from herself, her partner, a longtime friend, and three treating providers, including Dr. Anderson, who all maintained that Zayn’s progressive, incurable disease left her unable to perform full-time work. Unum disagreed and upheld its denial; this action followed. The parties stipulated that de novo review governed and that the dispute would be resolved on cross-motions for judgment under Federal Rule of Civil Procedure 52. After weighing the extensive record, the court credited the opinions of Dr. Anderson, who authored five separate disability opinions over the course of the claim, examined Zayn regularly for more than five years, and whose chart notes documented both subjective and objective findings corroborating the progression of her symptoms. The court explained, “‘This evidence alone is persuasive evidence [that plaintiff] is totally disabled,’ especially given the consistency of plaintiff’s symptom reporting and the fact that there is otherwise nothing in the record to suggest plaintiff has overstated her symptoms or is not credible.” The court also found that the largely consistent opinions of Zayn’s other treating providers also supported her claim. In contrast, the court found Unum’s consulting physicians less reliable, noting that none had personally examined Zayn, that two had relied in part on information mistakenly drawn from another claimant’s file, and that one review only addressed a neuropsychological evaluation performed nearly three years before Unum terminated benefits. The court also concluded that Unum overstated the significance of Zayn’s activities. The court conducted “an independent review of the record” which “reveals that these activities were relatively minimal, not transferrable to sustained employment, and consistent with the medical record and plaintiff’s other self-reports.” The court also found the corroborating statements from Zayn’s partner and friend to be persuasive evidence of disability, and treated the Social Security Administration’s disability determination as probative, especially because Unum “wholly fails to meaningfully reconcile” that award with its denial. In sum, the court concluded that “plaintiff suffers from a chronic, degenerative condition that results in cognitive impairments and fatigue which prevent plaintiff from attending work on a reliable and consistent basis, and, when at work, concentrating on her duties.” The court thus granted Zayn’s motion for judgment and denied Unum’s. The court awarded retroactive benefits and directed the parties to meet and confer regarding the appropriate amount of back benefits, interest, and reasonable attorney’s fees and costs.

ERISA Preemption

Sixth Circuit

Commonwealth of Kentucky ex rel. Coleman v. Express Scripts, Inc., No. 25-5866, __ F. 4th __, 2026 WL 2796078 (6th Cir. Sept. 18, 2026) (Before Circuit Judges Sutton, Gibbons, and Davis). The Commonwealth of Kentucky brought this action against several health care companies, including two pharmacy benefit managers (PBMs), Express Scripts, Inc. and Optum. Kentucky contends that these companies contributed to the state’s opioid crisis by negotiating with drug manufacturers to give opioids preferred placement on national drug formularies in exchange for rebates and fees, in violation of state consumer protection and nuisance laws. The PBMs administer prescription drug benefits for a mix of federal and commercial health plans. (For example, Express Scripts serves federal employee plans under the Federal Employees Health Benefits Act and provides pharmacy benefit and mail-order services for the Department of Defense’s TRICARE program, while Optum administers pharmacy benefits for the Veterans Health Administration.) The PBMs removed the case to federal court under the federal officer removal statute, 28 U.S.C. § 1442(a)(1), and Kentucky moved to remand, arguing that “its complaint effectively disclaimed liability for any conduct the firms undertook at the behest of a federal officer.” The district court agreed with Kentucky and granted the motion. However, shortly afterward, earlier this year, the Sixth Circuit decided Ohio ex rel. Yost v. Ascent Health Services, LLC. In that case the appellate court “rejected Ohio’s similar effort to avoid federal jurisdiction by disclaiming its intent to hold the PBMs liable for federally controlled conduct.” Relying on Yost, the Sixth Circuit reversed in this published opinion, finding federal jurisdiction was appropriate. The court noted that the federal officer removal statute “permits removal if the defendant establishes that: (1) he is a federal officer or a person ‘acting under’ a federal officer, (2) the lawsuit targets conduct ‘for or relating to any act under color of [federal] office,’ and (3) the lawsuit ‘involves a colorable federal defense.’” The court held that all three elements were met. First, the PBMs “acted under an officer of the United States” because their negotiations with drug manufacturers on behalf of federal plan sponsors are performed under the contractual control and oversight of the federal government. Second, Kentucky’s claims “relate to” that federally supervised conduct, because the PBMs negotiate rebates and set formulary placement through a unitary negotiation with drug manufacturers: “As the PBMs point out, there is little to no daylight between their federal and non-federal conduct as it pertains to negotiations with drug manufacturers.” Thus, the PBMs’ federal conduct was “indivisible” from its non-federal conduct, and Kentucky could not separate them for jurisdictional purposes. Third, the PBMs raised colorable federal defenses, including government-contractor immunity and preemption law under the FEHBA and TRICARE statutes. Where is ERISA in all this, you may wonder? Well, Optum contended that it had a colorable argument that ERISA preempts Kentucky’s claims, and the Sixth Circuit agreed: “[A] colorable argument exists that ERISA preempts Kentucky’s claims because they take aim at how Optum structures its ‘standard formulary offerings’ for ERISA plans.” The court cited Pharmaceutical Care Mgmt. Ass’n v. Mulready (the case of the week in our August 23, 2023 edition) in support, noting that there the Tenth Circuit held that Oklahoma’s PBM regulations were preempted by ERISA. The court also explained that five other circuits had examined similar issues, and “concluded that a complaint targeting PBM services performed holistically for federal and non-federal clients necessarily targets federal conduct.” Two of those circuits – the Second and Eighth – “have embraced all of these conclusions in precisely today’s setting: government lawsuits arising from the opioid crisis that target the PBMs’ indivisible rebate negotiations and formulary placement practices.” In its briefing, Kentucky did not have much to work with because of Yost. It only argued that the case should be remanded to the district court for that court to apply Yost in the first instance. The Sixth Circuit saw no point, stating that “where the dispute turns ‘principally [on] a question of legal theory rather than historical fact’…there is little benefit to sending the case back to a factfinder when no material facts remain to be found.” The court noted that “Kentucky remains free (with the district court’s leave) to excise from its complaint any claims giving rise to federal jurisdiction…[b]ut as it stands, Kentucky’s current complaint targets conduct that supports removal jurisdiction as to each of the relevant claims.” The court thus reversed the district court’s remand order and the case will proceed below.

Life Insurance & AD&D Benefit Claims

Fourth Circuit

Hughes v. Truist Bank, No. 3:26-CV-00510-KDB-MTO, 2026 WL 2823411 (W.D.N.C. Sept. 21, 2026) (Judge Kenneth D. Bell). Anthony Hughes was employed by Truist Bank and participated in the Truist Financial Corporation Employee Benefit Plan. The plan was an ERISA-governed welfare benefit plan for which Hartford Life and Accident Insurance Company served as the insurer and claims administrator. Hughes enrolled in accidental death and dismemberment (AD&D) coverage and elected the maximum available amount, ten times his annual salary, or $830,000, which the plan defines as the “Principal Sum.” Hughes alleged that he was led to believe this amount applied equally to the death of a spouse, and that he was not adequately informed that spousal AD&D coverage was limited to 50% of his elected amount. Instead, that limitation was “buried several layers deep in non-obvious hyperlinks” on the benefits portal or, at times, absent from the portal altogether. He further alleged that “Truist’s Benefits Administration Manager admitted that such information was ‘NOT easy to locate’ and the manager ‘could see how’ the language could be misleading.” (Hughes alleged that Truist “subsequently modified the portal to ‘make the limitation more visible.’”) Sadly, Hughes’s wife died in an accident in 2024. Hughes submitted a claim under the plan for the full $830,000 Principal Sum, but, citing the plan’s spousal limitation, Hartford approved only half of that, or $415,000. Hughes’s appeal was unsuccessful so he brought this action against Truist and Hartford asserting a claim for benefits under 29 U.S.C. § 1132(a)(1)(B) (Count I), a bundle of claims in Count II alleging breach of the duties of loyalty and prudence, failure to make disclosures required by 29 C.F.R. §§ 2520.102-2 and 2520.102-3, and a request for equitable relief reforming the plan’s communications, under 29 U.S.C. § 1132(a)(3), and a state law claim for misrepresentation and concealment (Count III). The case was transferred from the Northern District of Georgia (as we recounted in our July 1, 2026 edition), after which defendants moved to dismiss. As a threshold matter, the court declined to dismiss the complaint as an impermissible “shotgun pleading,” finding that, while not a model of clarity, it provided fair notice of the claims when read together with the parties’ briefing. The court also addressed which extrinsic documents it could consider on a motion to dismiss without converting it to one for summary judgment, holding that the plan document and summary plan description (SPD) were integral to the complaint and could be considered. The court declined to consider Hughes’ administrative appeal and adverse benefit notice because the other documents were sufficient to resolve the motions. On Count I, the court held that the SPD’s chart specifying that a spouse is covered at 50% and each dependent child at 15% of the Principal Sum unambiguously resolved the dispute in defendants’ favor. The court found this interpretation “plain and ordinary” and that it “unambiguously limit Hughes’s benefits for his spouse’s untimely passing.” Turning to the fiduciary duty claim, the court held that neither Truist nor Hartford was acting as a fiduciary when it came to the design of the benefits portal because the design of a portal’s layout and hyperlinks is a ministerial, not discretionary, function. Treating website design choices as fiduciary conduct “would risk expanding fiduciary duties well beyond the text of ERISA and its common law roots in trusts.” The court further held that, even if defendants had been acting as fiduciaries, Hughes’ allegations did not plausibly allege a breach, because “ERISA does not impose a general duty requiring ERISA fiduciaries to ascertain on an individual basis whether each beneficiary understands the collateral consequences of his or her particular election.” On the disclosure claim, the court found that neither 29 C.F.R. § 2520.102-2 nor § 2520.102-3 imposes any requirement that a plan maintain a participant portal, let alone one structured in a particular way. It also discounted Hughes’ allegations regarding the admission by Truist’s benefits manager, noting that Hughes’ “misunderstanding was not motivated by his conversation with the Truist employee,” as well as his allegations regarding Truist’s modification of the portal, stating that “subsequent remedial measures do not establish wrongdoing.” As for equitable relief, the court held that § 1132(a)(3) functions as a “catchall” available only for injuries not adequately redressed elsewhere in ERISA’s remedial scheme, and that Hughes could not use it as an “end around” for his failure to state a claim under § 1132(a)(1)(B). Finally, the court held that Hughes’ state law misrepresentation and concealment claims were preempted, explaining that they rested on the same allegations underlying his ERISA claims and constituted an impermissible alternative enforcement mechanism. The alleged misconduct was undertaken pursuant to defendants’ purported fiduciary duties and tied throughout to the plan, its coverage, and Hughes’ benefit election, and thus ERISA controlled. The court thus granted both motions to dismiss.

Medical Benefit Claims

Ninth Circuit

Doe v. The Signature Benefits Plan & the Disney Severance Pay Plan, No. SA CV 24-2230 DMG (DFMx), 2026 WL 2790684 (C.D. Cal. Sept. 17, 2026) (Judge Dolly M. Gee). In this action plaintiff Jane Doe sought reimbursement under an ERISA-governed, self-funded welfare benefit plan sponsored by The Walt Disney Company for residential treatment received by her minor dependent, S.J. Sadly, S.J. has a longstanding history of “major depressive disorder, generalized anxiety disorder, suicidal ideation, and past suicide attempts.” Between April 2023 and February 2024, S.J. was hospitalized three times for suicidal ideation and self-harm, and following the third hospitalization S.J.’s treating psychiatrist gave his “unequivocal recommendation” that S.J. should attend a residential treatment center (RTC). The doctor identified Compass Behavioral Health, an out-of-network provider, as the only local program suited to S.J.’s needs. The plan delegated claims administration for medical benefits to Cigna, which in turn used Evernorth Behavioral Health (EBH) to make medical necessity determinations under the plan’s medical criteria, the MCG Behavioral Criteria Guidelines. EBH initially identified partial hospitalization (PHP) as the appropriate level of care. When Compass sought authorization for higher-level RTC treatment, EBH’s peer reviewer, Dr. Peter Volpe, denied the request as not medically necessary. In doing so Dr. Volpe relied principally on a peer-to-peer conversation he had conducted several weeks earlier with one of S.J.’s psychiatrists, before S.J.’s condition worsened. S.J. was nonetheless admitted to Compass’s RTC program. Doe pursued an expedited internal appeal, which EBH’s Dr. Devinalini Misir denied on largely the same grounds as Dr. Volpe. An external reviewer (MCMC Services, LLC) then upheld the denial, although it did so using a definition of “medical necessity” that appeared nowhere in the plan documents. S.J. later stepped down to PHP-level care at Compass. Doe filed this suit under 29 U.S.C. § 1132(a)(1)(B), and the court held a half-day bench trial, ordering supplemental briefing on the scope of the administrative record before issuing findings of fact and conclusions of law under Federal Rule of Civil Procedure 52. First, the court tackled the standard of review. The court held that de novo review governed, because although the plan gave Disney “full discretion” to interpret plan terms and determine eligibility, nothing in the plan unambiguously delegated that discretionary authority to Cigna or EBH. The court explained that merely assigning Cigna the task of “determining medical necessity” fell short of an unambiguous grant of interpretive authority. The court further held that, because the plan made the external reviewer’s decision “final and binding” on Disney, the administrative record properly included the materials Doe submitted in connection with the MCMC external review, not just those considered by EBH. As for the merits, the court found that S.J.’s RTC treatment at Compass “was medically necessary under the MCG Guidelines,” i.e., Doe “has proven by a preponderance of the evidence that residential treatment was necessary, appropriate, and not feasible at a lower level of care.” The court credited the consistent, substantially corroborated opinions of S.J.’s treating providers over the opinions of EBH’s non-treating reviewers and the external reviewer. The court found Dr. Volpe’s denial unreliable because it rested on a peer-to-peer review that predated a material deterioration in S.J.’s condition and ignored a more recent, more informed recommendation from S.J.’s physicians. The court also found Dr. Misir’s appeal denial unsupported because it invoked criteria – such as impairment “across multiple settings” and a need for “24 hour psychiatric intervention” – that do not appear in the MCG Guidelines. The MCMC external reviewer’s decision was also entitled to little weight because it applied a medical necessity definition drawn from nowhere in the plan and relied on journal articles that were neither included in the record nor explained. As a result, the court granted Doe’s motion for judgment and denied Disney’s cross-motion. The court further held that Doe was entitled to benefits and reimbursement of her out-of-pocket costs for S.J.’s treatment under the plan’s single-case agreement provision, with interest. The court directed the parties to confer on the amount due and submit a proposed judgment, with Doe permitted to move for attorneys’ fees. (Disclosure: Doe was represented by former Kantor & Kantor attorney and friend of the newsletter Elizabeth K. Green.)

Pleading Issues & Procedure

Sixth Circuit

Montgomery v. Smith, No. 3:23-cv-00275, 2026 WL 2720533 (M.D. Tenn. Sept. 15, 2026) (Judge Aleta A. Trauger). Gary Montgomery brought this pro se action against twelve defendants over the division of assets in his divorce from Leslie Burnett Montgomery, presided over by state court judge Philip E. Smith, who passed away in 2022. Gary is currently incarcerated. (For more on his very serious legal troubles, check out this summary from 2021.) Judge Smith’s final decree found that two parcels – the Lakeview Property and the Donna Hill Property – were marital property. The Lakeview Property had originally been purchased solely by Gary and titled to a solo 401(k) plan of which he was trustee (entertainingly titled the “Bzbzbzboy Inc. 401k plan”), but Judge Smith found it had been funded in part with proceeds from a loan against Leslie’s own 401(k) account. His decree ordered the Lakeview Property sold, directed that an approximately $40,000 IRS debt attributed to Gary and an HVAC loan be paid from the sale proceeds, and split the remainder between the parties, with Gary’s share held in a court-controlled escrow account pending finality. When Gary, from custody, resisted cooperating with the sale, Judge Smith entered further orders in 2021 and 2022 removing him and appointing Leslie as trustee and plan administrator of the 401(k) plan for the limited purpose of consummating the sale. Gary’s operative complaint in this action alleges that Judge Smith’s orders “destroyed” the plan and “unreasonably debased [his] retirement account and its ability to earn/grow in the future.” He further alleges that Leslie, once given control of the Donna Hill Property’s rental income, breached a fiduciary duty to the plan by commingling that income with her personal funds. Gary’s complaint also alleges a number of other claims, including federal civil rights violations against Judge Smith, violation of the Real Estate Settlement Procedures Act (RESPA) by a group of real estate professionals involved in the Lakeview Property sale, and various state-law theories. Nine of the twelve defendants (the other three, including Leslie, have not yet appeared due to service issues) moved to dismiss. In a 2024 report and recommendation (R&R), a magistrate judge recommended that all four pending motions be granted, largely based on the Rooker-Feldman doctrine (described in more detail below). Gary did not timely object, and the court accepted the R&R. After Gary represented that he had never received the R&R, the court reopened the case in 2026 for the limited purpose of allowing Gary to object; his objections were addressed in this ruling. The court agreed with the magistrate that Gary’s claims against Judge Smith were barred by judicial immunity, as all of the challenged conduct occurred in Judge Smith’s judicial capacity while presiding over the divorce, and his official-capacity claims were barred by Eleventh Amendment sovereign immunity. As for the real estate agents, brokers, and title companies, Gary’s claims against them were barred by Rooker-Feldman and, in any event, his “broad and non-specific allegations” failed to explain what defendants had done in any detail. Because of these rulings, the only remaining basis for federal jurisdiction was Gary’s ERISA claims against Leslie. Because Leslie had not made an appearance (indeed, had not even been served), the court addressed those claims sua sponte, which it was allowed to do because Gary’s complaint raised a jurisdictional issue under Rooker-Feldman. Rooker-Feldman applies in “[(1)] cases brought by state-court losers [(2)] complaining of injuries caused by state-court judgments [(3)] rendered before the district court proceedings commenced [(4)] and inviting district court review and rejection of those judgments.” The court held that each item of relief Gary sought against Leslie under ERISA – an injunction undoing the Lakeview Property sale and restoring him as plan trustee and administrator, an order requiring Leslie to pay over rental income collected since 2016, and an order requiring her to repay amounts used toward the IRS and HVAC debts – would necessarily require undoing some portion of Judge Smith’s final decree or the orders implementing it. The court found this true even though Gary did not expressly ask it to vacate the final decree: “the plaintiff ‘can only prevail’ on his claims against [Leslie] for injunctive relief ‘if the state court were wrong,’ making it clear that the Final Decree and subsequent orders are ‘the source of the injury.’” Furthermore, to the extent Gary sought damages rather than equitable relief, “the only source of his alleged injury is the above-referenced wrongs, and an award of damages for actions taken in accordance with the Final Decree would likewise require setting aside Smith’s division of assets in the divorce.” As a result, Rooker-Feldman barred Gary’s ERISA claims against Leslie. Gary did not respond to the magistrate’s Rooker-Feldman analysis in his objection, which did not help. Having dismissed every claim over which it possessed original jurisdiction, the court declined to exercise supplemental jurisdiction over the remaining state law claims, as to all defendants, and dismissed them without prejudice.

Provider Claims

Seventh Circuit

Marion HealthCare, LLC v. Aisin Manufacturing Illinois, LLC, No. 3:25-CV-1719-NJR, 2026 WL 2718233 (S.D. Ill. Sept. 15, 2026) (Judge Nancy J. Rosenstengel). Marion HealthCare, LLC and Marion Anesthesia Company, LLC are Illinois healthcare providers. They rendered medical services to 65 employees of Aisin Manufacturing Illinois, LLC, who were covered under Aisin’s self-funded, ERISA-governed group health plan, administered by Anthem Blue Cross and Blue Shield. Before receiving services, each patient allegedly verified coverage with Anthem by phone or online and attempted to assign their benefits, claims, and causes of action under the plan to plaintiffs. Across all 65 patients, total charges were $895,454.77, but the plan only reimbursed $183,684.29. Plaintiffs exhausted their administrative appeal rights and this action followed against Aisin and Anthem, asserting two ERISA counts along with four state-law claims for fraud and promissory estoppel, seeking the unpaid balances, fees, and damages. Aisin and Anthem separately moved to dismiss the operative complaint, each arguing principally that the court lacked subject matter jurisdiction because plaintiffs lacked standing, and alternatively raising venue, preemption, and pleading deficiencies. The court began and ended its discussion of the motions with standing. The court explained that civil actions to recover plan benefits may be brought only by plan participants or beneficiaries, and thus plaintiffs, as healthcare providers, could sue only if they had derivative standing through a valid assignment from their patients. Because the parties had submitted both a 2015 and a 2024 version of the plan without clarifying which governed, the court analyzed standing under both, observing that each contained “an express anti-assignment or nonalienation provision” that voided any attempt to assign, transfer, or encumber rights under the plan. Plaintiffs raised three arguments for why this provision was inapplicable, but the court rejected them. First, it found no support for reading the 2015 plan’s anti-alienation clause as limited to situations involving bankruptcy or creditors simply because an adjacent subsection addressed bankruptcy. Second, the court rejected plaintiffs’ contention that provisions authorizing direct payment to providers superseded the anti-alienation clauses. The court held that under “the canon of harmonious reading,” a plan can “allow[] direct payment to service providers and, simultaneously, expressly prohibit[] assignment of Benefits to service providers.” The court cited numerous cases supporting its conclusion, which “emphasized the increasing trend of district and circuit courts holding that anti-assignment provisions in ERISA plans may preclude a provider from bringing actions under the Act.” Third, the court rejected plaintiffs’ argument that defendants’ acceptance of administrative appeals from plaintiffs constituted a waiver of their standing defense. The court held that permitting a provider to pursue internal appeals as an authorized representative does not confer standing to pursue a civil action, and further noted that the 2015 plan contained an express no-waiver clause. Having concluded that both the 2015 and 2024 plans validly barred assignment of participants’ claims to plaintiffs, the court thus held that plaintiffs lacked statutory standing to pursue their ERISA counts and that the court lacked subject matter jurisdiction over them. The court declined to exercise supplemental jurisdiction over the four remaining state-law fraud and promissory estoppel claims. As a result, the court granted defendants’ motions in full and dismissed the complaint without prejudice.

Withdrawal Liability & Unpaid Contributions

Seventh Circuit

Consumers Concrete Corp. v. Central States, Se. & Sw. Areas Pension Fund, Nos. 25-1765 & 25-1766, __ F. 4th __, 2026 WL 2752196 (7th Cir. Sept. 17, 2026) (Before Circuit Judges Easterbrook, Ripple, and Lee). Consumers Concrete Corporation participated in a multiemployer pension plan administered by Central States, Southeast and Southwest Areas Pension Fund. Consumers partially withdrew from the plan in 2017 and completely withdrew in 2019, triggering the Multiemployer Pension Plan Amendments Act’s (MPPAA) withdrawal liability rules. Those rules involve determining “the allocable amount of unfunded vested benefits,” which is then adjusted in a four-step process. The parties agreed that Consumers’ allocable share of unfunded vested benefits for its 2019 complete withdrawal was $23,272,103.41 and that its resulting annual payment, before any credit for its 2017 withdrawal liability, was $607,344.90. They disputed only how to apply the 2017 credit. Consumers argued the credit should be subtracted only after all four steps were complete, including the twenty-year cap on annual payments in step three, which would reduce the present value of its liability to $9,306,831.24 or, if the credit exceeded that figure, to zero. The Fund argued the credit should be applied earlier, at step two, before the cap was applied, and thus Consumers was required to pay $9,306,831.24 over the next 20 years. The parties arbitrated the dispute, and the arbitrator ruled in favor of the Fund. Both sides sought review in the district court, which consolidated the two cases. The district court vacated the arbitration award, agreeing with Consumers that its credit should be applied only after all four steps had been completed. The Fund appealed, and the court invited the Pension Benefit Guaranty Corporation (PBGC) to weigh in as an amicus; the Chamber of Commerce also filed an amicus brief in support of Consumers. The Seventh Circuit acknowledged that the MPPAA was “an intricate statutory scheme with detailed calculations,” that this was “a tough case,” and “[t]here are reasonable arguments on both sides.” However, the appellate court ultimately sided with Consumers. It reasoned that § 1381(b) (which outlines the four-step process) defines “withdrawal liability” as the amount that results only after all four adjustment steps are applied, and that § 1386(b)(1), which directs that a partial withdrawal credit “shall be reduced” from “any withdrawal liability…in a subsequent plan year,” operates on that fully adjusted figure rather than on an intermediate amount calculated during the process. The Fund argued that step two’s invocation of § 1386 meant that the credit had to be applied before proceeding to step three, but the Seventh Circuit disagreed. The court read § 1381(b)(1)(B)’s cross-reference to § 1386 as “forward-looking, not back-looking.” In other words, when an employer undertakes a partial withdrawal, the plan sponsor calculates that withdrawal’s liability under § 1386(a) and records it as a credit to be applied against a later, subsequent withdrawal once that later withdrawal’s liability is itself fully calculated. “To put it another way, § 1386(b)(1) focuses on the time that the partial withdrawal liability is first calculated, not when the subsequent liability (whether complete or partial) is determined – which could be any number of years later.” The court found support for this reading in the PBGC’s longstanding interpretation of the statute, which was reiterated by the PBGC in its amicus brief, that “withdrawal liability ‘shall be reduced’ is best understood to operate on the fully-adjusted amount of withdrawal liability determined under § 1381(b)(1), rather than on intermediate figures in the calculation process.” In reaching this result, the Seventh Circuit expressly acknowledged that it was creating a circuit split, respectfully disagreeing with decisions from the Ninth and Eleventh Circuits on this issue. Both of those decisions authorized funds to apply the credit at the step-two stage. The panel noted, “Because this opinion disagrees with Eleventh and Ninth Circuits, we have circulated it to all judges of this court in regular active service in accordance with Circuit Rule 40(e). No judge requested to rehear this case en banc.” Either this was a slam-dunk for the other Circuit judges or withdrawal liability is simply too boring to get worked up about.