T.E. v. Anthem Blue Cross & Blue Shield, No. 25-5407, __ F.4th __, 2026 WL 172050 (6th Cir. Jan. 22, 2026) (Before Circuit Judges Griffin, Thapar, and Hermandorfer)

The tide appears to be turning in medical benefit cases. For years consumers have grown accustomed to receiving opaque and uninformative denial letters from their health insurers. These letters were often tolerated by the courts, which found the denials acceptable partly due to the deferential standard of review they were typically required to apply under ERISA.

However, it appears the courts have become increasingly frustrated with such denial letters and are beginning to scrutinize them more closely, regardless of the operative standard of review. The Tenth Circuit has led the way on this issue (see, e.g., Ian C. v. UnitedHealthcare Ins. Co. and D.K. v. United Behavioral Health), but other courts have weighed in as well (such as the Fifth Circuit in Dwyer v. UnitedHealthcare Ins. Co.; see below for this week’s attorney’s fees ruling in that case). Most of these cases have involved health insurance giant UnitedHealthcare.

This week it was the Sixth Circuit’s turn to express its displeasure, but this time with a different insurer: Anthem Blue Cross & Blue Shield. As a bonus, the court also discussed the 2008 Mental Health Parity and Addiction Equity Act (the “Parity Act”).

The plaintiff in the case was T.E., who sued individually and on behalf of his son, C.E. (initials were used for both because C.E. was a minor). Unfortunately, C.E. has a history of behavioral and mental health issues, including ADHD, anxiety, and autism. He received therapy and medication throughout his childhood, but in January of 2020 his condition worsened. C.E. exhibited aggressive behavior and suicidal ideation and was placed in a partial hospitalization program. C.E. did not improve, and thus he was moved to acute inpatient hospitalization for a few days.

C.E. returned to partial hospitalization, but he was discharged in February of 2020 with a recommendation that he “needed intensive in-patient treatment to address his symptoms.” T.E. then enrolled C.E. at Elevations, a residential treatment center.

Anthem, the administrator of the benefit plan covering C.E., initially approved coverage for two weeks at Elevations. It then approved another week of treatment based on Elevations’ comments that C.E. had “severe executive functioning” issues and “struggle[d] to self-regulate.”

C.E. did not improve, however; Elevations “noted that C.E was again confined to his dorm for safety reasons and would not follow staff instructions. C.E. also continued to be disruptive and argumentative, on top of reporting continued anger and feelings of aggression towards others.”

Despite this, Anthem denied coverage for further treatment at Elevations, stating it was no longer “medically necessary” under the plan’s guidelines. T.E. appealed, but to no avail. As a result, T.E. filed this action alleging that Anthem (1) arbitrarily and capriciously denied his claim for benefits, and (2) violated the Parity Act. The district court granted summary judgment to Anthem (Your ERISA Watch covered this ruling in our April 9, 2025 edition), and T.E. appealed to the Sixth Circuit.

The appellate court began with the standard of review, which both parties agreed was the arbitrary and capricious standard because the benefit plan at issue gave Anthem discretionary authority to make benefit decisions. The court reviewed the district court’s application of this standard de novo.

The Sixth Circuit explained that “ERISA’s arbitrary-and-capricious standard has both a procedural and substantive component.” However, the court never even reached the substantive component because “Anthem’s coverage decision was procedurally arbitrary and capricious.” The court ruled that this was so because “Anthem failed to ‘engage in reasoned decisionmaking’” in three different ways.

First, Anthem “inadequately assessed C.E.’s treating-clinician evidence.” The Sixth Circuit observed that three of C.E.’s treating clinicians had supported his continued treatment, but Anthem “never addressed the[ir] opinions,” did not “provide a reason for rejecting” those opinions, and “‘never explained’ their ‘disagreement with the opinions.’”

Instead, Anthem “decided, without explanation, to adopt the contrary opinions of its physician reviewers…based only on cursory ‘[f]ile reviews’ – rendering Anthem’s decision even more ‘questionable,’ particularly given that T.E.’s claim ‘involves a mental illness component.’” This “total failure to address the opinions of C.E.’s treating clinicians falls short of the meaningful review ERISA requires.”

Anthem argued that it did consider the clinicians’ opinions. However, the Sixth Circuit explained that Anthem only mentioned some of the opinions, “did not address the crux” of their evidence, contradicted some of the clinicians’ evidence, ignored evidence that cut against its decision, and offered conclusory statements about the scope of its review. In short, Anthem failed “the bare minimum required by our caselaw,” which is to “‘give’ some ‘reasons’ for rejecting the opinions of the participant’s treating doctors… Anthem failed to do so. All told, Anthem shut its eyes to the medical opinions of C.E.’s treating clinicians, which suggests that its coverage denial was arbitrary and capricious.”

Second, the Sixth Circuit accused Anthem of evidentiary cherry-picking, which is “a hallmark of arbitrary-and-capricious decisionmaking.” The court found that one of Anthem’s physician reviewers quoted parts of C.E.’s medical records while ignoring others, and “never explained why he privileged one portion of the notes over the other or how he reconciled the conflicting evidence.” Another reviewing physician incorrectly interpreted C.E.’s milieu notes, which actually indicated ongoing struggles rather than improvement.

Third, the Sixth Circuit found that Anthem “failed to ‘adequately explain[] any change from an earlier benefits ruling.’” The court noted that Anthem covered the first 21 days of C.E.’s treatment, but then denied further coverage without identifying “a rational reason” for doing so.

The court examined the appeal denial letters, the initial denial letter, and the physician reviewer reports to find such a reason, but none satisfied ERISA’s requirements. The appeal denial letters misrepresented C.E.’s condition and contradicted its clinical guidelines. The initial denial letter misrepresented the medical records, nebulously referred to “improvement” without explaining how that changed coverage, and cited facts which were irrelevant to Anthem’s coverage determination. The physician reviewers either “offered only bottom-line conclusions, devoid of any explanation,” or “misstated the record and never addressed why treatment was no longer needed to address C.E.’s ‘mood disorder’ and ‘severe executive functioning’ issues.”

In sum, “Anthem justified its coverage denial by citing considerations that were unrelated to C.E.’s initial admission and contradicted its prior assessment. Anthem’s justification for its coverage-decision change was, in short, irrational.”

As for a remedy, the Sixth Circuit ruled that remand was appropriate. The court stated that while “T.E. has put forth evidence that C.E.’s treatment is medically necessary under Anthem’s coverage guideline,” the court was not a “medical specialist” and thus it would not make a coverage determination in the first instance. “The ‘proper remedy’ in such a case is to vacate the district court’s decision and remand with instructions that the district court remand to the plan administrator for ‘a full and fair inquiry.’”

The decision was not a total victory for T.E., however, as the Sixth Circuit turned next to his Parity Act claim. The court acknowledged that to date it had “neither interpreted nor applied the Parity Act,” and in fact, “we have not even accepted that there is a private cause of action to enforce the Parity Act[.]”

However, the court found it unnecessary to “resolve here exactly how to evaluate Parity Act claims because T.E.’s claim fails in any event.” The court noted that, “[a]t a minimum, the statutory text directs that Parity Act claims require a comparison between an insurer’s treatment limitations for mental-health care and the treatment limitations for medical or surgical care.” Such an analysis requires plaintiffs to “demonstrate what those medical or surgical treatment limitations are and how they apply in practice.”

Here, however, the Sixth Circuit ruled that T.E. did not identify the comparable medical/surgical guidelines or how they applied. The court stated that T.E. also “failed to identify evidence of how those limitations are ‘separate’ from or less ‘restrictive’ than Anthem’s ‘treatment limitations’ on mental-health care.” As a result, even if T.E. could bring a private right of action under the Parity Act, he did not satisfy his burden of proof, and thus the court affirmed the judgment in Anthem’s favor on this claim.

Despite the court’s Parity Act ruling, the decision can only be considered a huge success for T.E., and will certainly assist plan beneficiaries looking to challenge future health insurance denials.

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

Arbitration

Second Circuit

Moody v. Starbucks Corp., No. 25-CV-8739 (PAE) (BCM), 2026 WL 146404 (S.D.N.Y. Jan. 20, 2026) (Judge Barbara Moses). Amari J. Moody, proceeding pro se, brought this action “alleging claims under the Americans with Disabilities Act (ADA)…the Family Medical Leave Act (FMLA)…and the Employee Retirement Income Security Act of 1974 (ERISA)…all arising out of the termination of his employment in August 2025, ‘while Plaintiff’s approved medical leave…remained active.’” Starbucks filed a motion (1) to dismiss the ADA claim, (2) for failure to exhaust required administrative remedies, and (3) to compel arbitration of all of plaintiff’s claims. The court granted Starbucks’ motion to compel arbitration, noting that Moody had signed an arbitration agreement as a condition of his employment, which required arbitration for employment-related claims. The court found that the agreement was valid and that all of Moody’s claims fell within its scope. The court acknowledged that “[i]n some cases, the court must also consider whether the plaintiff’s federal statutory claims are exempt from the reach” of the Federal Arbitration Act, but “[t]hat is not an issue here. It is well-settled that individual claims under the ADA, the FMLA, and ERISA are arbitrable… Shafer v. Stanley, 2023 WL 8100717, at *20 (S.D.N.Y. Nov. 21, 2023) (‘Second Circuit law makes clear that compulsory arbitration of ERISA claims is lawful.’).” Moody contended that Starbucks waived its right to compel arbitration by “engaging in litigation-stage conduct fundamentally inconsistent with that right, including merits briefing, submission of fact-disputed declarations, and continued post-notice retaliation following formal litigation notice,” but the court found this argument “borders on the frivolous.” The court observed that Starbucks had timely and repeatedly informed the court that the case belonged in arbitration, and had not participated in any discovery or other litigation activities that would suggest a waiver. As a result, the court sent the case to arbitration and stayed all matters pending its completion.

Attorneys’ Fees

Fifth Circuit

Dwyer v. UnitedHealthcare Ins. Co., No. A-17-CV-439-RP, 2026 WL 184247 (W.D. Tex. Jan. 21, 2026) (Magistrate Judge Mark Lane). In 2017, Kelly Dwyer sued UnitedHealthcare Insurance Company, the administrator of his ERISA-governed medical benefit plan, for wrongfully terminating mental health benefits for his daughter and for failing to process claims under the correct rates in the plan. After a 2019 bench trial, the district court ruled against Dwyer almost four years later, in March of 2023, on both arguments. Dwyer appealed, and in 2024 the Fifth Circuit reversed in a published decision that was highly critical of United. (That ruling was Your ERISA Watch’s case of the week in our September 25, 2024 edition.) The Fifth Circuit ruled that United’s denial letters were unhelpful and unsupported by medical evidence, and that United failed to conduct a meaningful dialogue with Dwyer when handling his claims. The Fifth Circuit further ruled that United had forfeited the right to contest the issue of the correct rates because it never responded to Dwyer’s internal appeal. The Fifth Circuit remanded, and in this report and recommendation the assigned magistrate judge addressed the issues of attorney’s fees, costs, and interest. First, the court applied the Fifth Circuit’s five-factor test to determine whether fees should be awarded at all. The court ruled that all five factors favored an award. The court stated that the Fifth Circuit “made clear that United was entirely culpable for Dwyer’s damages,” “[t]he court has no doubt that United can satisfy an award of attorneys’ fees,” “the court can only hope that such an award may cause United to pause before acting again under similar circumstances,” “Dwyer…sought to make clear to United that it could not treat other plan beneficiaries the way it treated him,” and “as made clear by the Fifth Circuit, United had little to no merit in its position. Accordingly, Dwyer has shown that a fee award is appropriate.” The court then applied the lodestar method – multiplying a reasonable hourly rate by the hours reasonably spent on the case – to determine an appropriate fee. The court acknowledged that “[g]enerally, the ‘relevant market for purposes of determining the prevailing rate to be paid in a fee award is the community in which the district court sits.’” However, based on the declarations of Dwyer and his counsel, the court was “satisfied that Dwyer has shown the necessity of turning to out-of-district counsel for representation in this matter.” As a result, it awarded the prevailing market rates in the Central District of California, where Dwyer’s counsel was located, ranging from $800-900 per hour. The court also found that using the attorneys’ current rates was reasonable to compensate them for the fact that they took the case on contingency and had not been paid “for the nearly decade of time that has gone by.” The court dismissed United’s concerns about the rates, stating, “United did not illustrate its point by sharing how much it spent in fighting to deny $109,063.50 in benefits of life-saving treatment for a child.” Next, the court examined the hours spent on the case by Dwyer’s counsel and ruled that they were mostly reasonable as well. Again, the court noted that Dwyer’s attorneys worked on contingency and thus “had no incentive to spend unnecessary time on this case.” The court examined United’s individual arguments regarding certain tasks, and reduced minor time for travel and clerical tasks, but largely dismissed its objections. In the end, the court “recognize[d] that the amount of attorneys’ fees far outpaces the amount recovered. United makes much of this. However, there is no indication that Dwyer could have recovered his benefits without the expenditure. Reducing the fee award would only make it harder for future plaintiffs to find vindication in the courts.” The court then turned to costs and interest. Dwyer sought litigation costs of $6,517.27 and prejudgment interest of $87,596.77 (8% compounded annually) beginning on the date of the Fifth Circuit’s ruling. The court found both justified, noting that Dwyer “was forced to drain his savings and refinance his home to pay for his daughter’s care.” Thus, in the end, the magistrate judge recommended granting Dwyer’s motion for attorneys’ fees, costs, and interest, with minimal reductions, and ordered Dwyer to submit a notice reflecting its reductions. (Disclosure: Kantor & Kantor LLP is counsel of record for Mr. Dwyer in this action.)

Breach of Fiduciary Duty

Fourth Circuit

Jacob v. RTX Corp., No. 1:25-CV-1389 (LMB/WBP), __ F. Supp. 3d __, 2026 WL 173228 (E.D. Va. Jan. 22, 2026) (Judge Leonie M. Brinkema). This is yet another case challenging an employer’s use of forfeited contributions to a retirement plan, and it ended in the same manner as the vast majority of similar cases preceding it. The plaintiffs, Melissa Jacob and Thomas Miller, were employees of aerospace and defense conglomerate RTX Corporation and participants in the RTX Savings Plan, an ERISA-governed 401(k) plan. Like many such plans, it is funded by participants and company matching contributions. Participants are immediately vested in their contributions, but matching contributions vest after two years of service. If a participant leaves before full vesting, unvested contributions are forfeited. Plaintiffs filed this putative class action alleging eight counts under ERISA against RTX and related defendants, including breaches of fiduciary duties and prohibited transactions. They contended that defendants improperly used forfeitures to offset future employer contributions instead of covering administrative expenses, reducing funds available for participants and depriving the plan of potential earnings. Defendants filed a motion to dismiss, which the court adjudicated in this published decision. First the court found that defendants acted in accordance with plan documents because the parties agreed that defendants did use forfeitures to pay some plan expenses, and because there was no plan provision requiring forfeitures to be used by the end of the year, as plaintiffs contended. Second, the court dismissed the claims for breach of ERISA’s duties of loyalty and prudence for similar reasons. The court stated that “Plaintiffs’ interpretation, which reads as a prioritization of using forfeitures to pay for administrative expenses instead of for reducing employer contributions into the Plan, is both unsupported by the language of the Plan, and the principles of ERISA.” Third, the court ruled against plaintiffs on their anti-inurement claim because “Plaintiffs’ Complaint does not allege any facts showing that defendants have removed any of the forfeited funds from the Plan.” On the contrary, the forfeitures remained within the plan and were used for permissible purposes. Defendants may have benefited from using forfeitures to reduce employer contributions, but such a benefit was only “indirect” and thus “insufficient to state a claim under the anti-inurement provision.” Fourth, the court found no prohibited transactions because the forfeitures remained within the plan, and the transactions at issue did not “present a special risk of plan underfunding” or otherwise harm the plan. Fifth, the court dismissed plaintiffs’ duty to monitor claim because it was derivative of plaintiffs’ other claims, which the court had already found failed to state a claim. In short, the court concluded that none of plaintiffs’ claims were supported by the plan’s language or ERISA principles, and thus it granted defendants’ motion to dismiss.

Eighth Circuit

Adams v. U.S. Bancorp, No. 22-CV-509 (NEB/LIB), 2026 WL 151825 (D. Minn. Jan. 16, 2026) (Judge Nancy E. Brasel). The plaintiffs in this putative class action are former employees of U.S. Bank who sued the bank and related defendants, alleging that they violated ERISA by underpaying early retirement benefits under the bank’s pension plan. Specifically, plaintiffs argued that defendants used unreasonable mortality tables and discount rates, which resulted in benefits that were not actuarially equivalent to those they would have received had they retired at the normal age of 65. Plaintiffs sought declaratory and equitable relief under 29 U.S.C. § 1132(a)(3), alleging breach of fiduciary duty and violations of 29 U.S.C. § 1054(c)(3) and 29 U.S.C. § 1053(a). In 2022, the court denied defendants’ motion to dismiss, but the court “left open whether actuarial equivalence, in practice, requires reasonable assumptions.” (Your ERISA Watch covered this ruling in our October 26, 2022 edition.) The parties conducted expert discovery, after which defendants filed a motion to exclude plaintiffs’ expert and a motion for summary judgment, both of which were granted in this order. The court ruled that the testimony of plaintiffs’ expert, Ian Altman, was inadmissible because his “methodology (a) uses an inapposite interest-rate assumption (b) as a brightline point of comparison, rather than measuring the Plan’s [early commencement factors (ECFs)] against a range of possible values.” The court noted that Altman used interest-rate assumptions from 26 U.S.C. § 417(e), which “is not in line with actuarial science or the practices of other actuaries.” Furthermore, his methodology “would require annually updating the underlying interest-rate assumption to reflect current market conditions,” which “would be ‘impractical and unprecedented’” and “would generate considerable administrative burdens for plan sponsors.” Also, “Altman’s approach, which assesses the Plan’s ECFs against a single data point rather than a range of values, is so unconventional as to be unreliable.” Thus, the court excluded Altman’s testimony as “untested, unsupported, and ultimately unreliable.” The court then moved on to defendants’ summary judgment motion and answered the question it had left open on their motion to dismiss: “[T]he Court concludes that actuarial equivalence does not require reasonable underlying assumptions.” The court explained that actuarial equivalence “is an exercise in relative comparison of value under consistent assumptions, not absolute value.” As a result, “a plan’s actuarial equivalence is properly assessed in reference to those assumptions and conversion factors stated in the plan document.” Under this lenient standard, the court concluded that the plan’s ECFs were “within a range of reduction factors that generate actuarially equivalent early retirement benefits.” The court noted that even if ERISA required “reasonable assumptions,” plaintiffs could not meet their burden on this issue because their expert had been excluded, and in any event defendants had presented evidence supporting the reasonableness of their ECFs. Furthermore, even if Altman’s evidence had been admitted, he failed to rebut defendants’ expert’s argument that the plan’s assumptions were reasonable, and conceded that “other assumptions, beyond those he used in his framework, could be reasonable and generate actuarially equivalent ECFs.” As a result, the court concluded that the plan did not violate ERISA and there was no breach of fiduciary duty. Defendants’ motions were granted, plaintiffs’ class certification motion was denied as moot, and judgment was entered for defendants.

Disability Benefit Claims

First Circuit

Butter v. Hartford Life & Accident Ins. Co., No. 24-11499-MJJ, __ F. Supp. 3d __, 2026 WL 172049 (D. Mass. Jan. 22, 2026) (Judge Myong J. Joun). Alison Butter was employed by Metrowest Jewish Day School and covered by the school’s employee long-term disability benefit plan, which was insured by Hartford Life and Accident Insurance Company. She stopped working in March of 2021 due to various health issues, including leg pain, neck pain, overall body pain, and fatigue. She was diagnosed with conditions including mild bilateral osteoarthritis, complex ovarian cyst, bilateral leg paresthesia/pain, cervical radiculopathy, fibromyalgia, chronic pelvic congestion, and Raynaud’s anemia of chronic disease. Hartford initially approved her claim for benefits, but in 2022 it conducted surveillance of Butter and requested that she undergo an independent medical examination (IME). Based on the IME findings, which concluded that Butter could perform various physical activities, such as sitting for up to 8 hours per day and walking for up to 60 minutes at a time, Hartford terminated Butter’s benefits in March of 2023, determining that she did not meet the plan’s definition of disability under the “Any Occupation” standard. Butter appealed, submitting her own IME report and the results of a functional capacity evaluation, but Hartford upheld its decision on appeal and this action followed. The parties filed cross-motions for summary judgment, which were decided in this published order. The court ruled that the abuse of discretion standard of review applied because the plan granted Hartford discretionary authority to determine benefit eligibility. Butter argued that this standard should be weakened because of Hartford’s structural conflict of interest as “both the adjudicator and payor of claims.” However, the court “agree[d] with Hartford” that this conflict “is not entitled to any weight” because there were no procedural errors in Hartford’s review. Turning to the merits, the court found that Hartford gave “undue weight” to the surveillance footage of Butter because its assessment “fails to consider her slow gait, the obvious struggle in her movements, and the short length of observation.” The court also criticized Hartford’s IME, noting that it contradicted the findings of Butter’s personal physicians and “provides no explanation” as to why those findings were less persuasive. The court further criticized Hartford for not adequately addressing the “years of documentation” of Butter’s chronic pain. The court noted that Hartford did a better job on appeal because it “grapple[d] more with the medical evidence submitted by Ms. Butter,” but it still “fails to explain why Ms. Butter would be capable of full-time functioning[.]” The court also cited Hartford’s finding that “there is no documentation of clinical findings to suggest total inability of activity, such as functional loss of strength/sensation and mobility/gait,” and stated that “[t]his misses the point” because it did not address Butter’s chronic pain symptoms. The court also critiqued Hartford’s assessment of Butter’s award of Social Security Disability Insurance benefits. Hartford only “provided a vague explanation for why an award of SSDI did not entitle her to long-term disability benefits,” and did “not sufficiently explain that the actual medical evidence it relied upon was different than that which was in the SSA’s possession, how it was different, and how it relied on vocational and behavioral evidence that differed from the SSA.” Because of all this, the court was “inclined to rule in Ms. Butter’s favor,” but “it would be unwise to take this step without first giving [Hartford] the chance to address the deficiencies in its approach.” Thus, the court remanded to Hartford “for further review in accordance with this decision.”

Sixth Circuit

Potthoff v. Unum Life Ins. Co. of Am., No. 1:24-CV-991, 2026 WL 177603 (W.D. Mich. Jan. 22, 2026) (Judge Paul L. Maloney). William Potthoff was a general and vascular surgeon who worked in Traverse City, Michigan, for more than 25 years. Throughout his career, Potthoff suffered from back pain, which led to the closure of his clinic in 2018. He began looking for new work, and at the same time Unum Life Insurance Company of America approved his claim for residual long-term disability benefits, which allowed him to work on a reduced schedule as recommended by his doctors. Seven months into his job search, Potthoff’s back pain worsened to the point he felt he could no longer return to work at all, so he applied for total disability benefits. Unum approved Potthoff’s claim, but classified his disability as arising from “sickness,” not “injury,” which was important because the policy insuring the plan limited benefits to 42 months for sickness, whereas benefits due to injury are payable for life. Potthoff appealed, contending that his back pain was due to a slip-and-fall accident in 1996, and from “repetitive stress injuries through decades of performing surgery as part of his high-volume practice.” However, Unum’s reviewing physicians concluded Potthoff’s back pain had started in 1995 and was due to degenerative disc disease, and thus upheld its determination that his disability was due to “sickness.” Potthoff then sued Unum under ERISA § 502(a)(1)(B), contending that he was entitled to benefits under the injury provision of the policy, and filed a motion for judgment on the administrative record, which the court reviewed in this order. The court applied a de novo standard of review because the plan did not give Unum discretionary authority to determine benefit eligibility. The court asked two questions: (1) “Did Potthoff’s slip-and-fall cause his total disability?”; and (2) “Did Potthoff’s repetitive stress injuries cause his total disability?” The court, noting the 20-year gap between the slip-and-fall and the disability, found “there is not enough evidence in the record to prove, more likely than not, that the slip-and-fall caused his total disability.” As for the repetitive stress argument, Unum’s policy defined “injury” as an “accidental bodily injury.” Unum argued that the court should apply Michigan law to interpret this term, but the court explained that because this was an ERISA case, federal common law applied. As a result, it applied the First Circuit’s Wickman test, borrowed by the Sixth Circuit, to determine whether Potthoff had suffered an “accident.” The court noted that “[c]ourts in the Sixth Circuit have so far only applied this test to accidental death policies,” but “[t]here is no…reason that the Sixth Circuit would limit its use of the First Circuit’s test only to accidental death policies,” and thus it adopted the test in the disability context as well. The Wickman test involves a subjective/objective inquiry, but “the record here does not reflect Potthoff’s subjective expectations about his injury.” As a result, the court evaluated “whether a reasonable person in the insured’s position (here, a reasonable general and vascular surgeon) with the insured’s same knowledge and experience might know or reasonably believe about whether developing their condition (like degenerative disc disease) is ‘highly likely.’” The court concluded that the answer was no. The medical studies in the record showing the connection between back pain and performing surgery did not appear until after 2018, and “although some of these risks could have been known to Potthoff during his working years, there is nothing in the record to reflect that a reasonable surgeon would have been aware of how his or her work affected his or her wellbeing in this way.” As a result, “it is…reasonable that Potthoff would not have known about the risk of repetitive stress injuries. Potthoff’s repetitive stress injuries are therefore ‘accidental.’” The court further determined that Potthoff’s work as a surgeon, which involved standing in contorted positions for long hours while wearing uncomfortable equipment, “more likely than not” led to his repetitive stress injuries and total disability. As a result, the court agreed with Potthoff that his total disability was due to “injury” and not “sickness.” As for a remedy, the court determined that the record “clearly establishes that Potthoff is totally disabled,” and thus remand was unnecessary; Unum was “not entitled to a ‘second bite at the apple’ during remand.” The court thus granted Potthoff’s motion for judgment and declaratory relief, and ordered the parties to meet and confer regarding the issues of interest, attorney’s fees, and costs.

Eleventh Circuit

Tunkle v. ReliaStar Life Ins. Co., No. 24-12563, __ F. App’x __, 2026 WL 144606 (11th Cir. Jan. 20, 2026) (Before Circuit Judges Newson and Brasher, and District Court Judge Paul C. Huck). Dr. Alyosha S. Tunkle was a general surgeon for 21st Century Oncology, Inc., which funded its employee long-term disability benefit plan with a group insurance policy issued by ReliaStar Life Insurance Company. The policy covered employees who worked at least 30 hours per week and excluded coverage for preexisting conditions. Due to complications from shoulder surgery, Dr. Tunkle developed a disabling tremor, which eventually forced him to stop working on July 30, 2020. His 2020 pay summaries showed he worked 40 hours per week until March 15, after which his hours and pay decreased significantly until May 23. His full-time work and salary resumed on May 24 and continued through mid-July. Dr. Tunkle submitted a claim for benefits to ReliaStar, but ReliaStar denied it, contending that Dr. Tunkle’s disability was caused by a preexisting condition. ReliaStar explained that it had obtained Dr. Tunkle’s pay summary and productivity reports, which showed that he did not work at least 30 hours per week between March 15 and late May 2020. As a result, Dr. Tunkle was not “actively at work” during this period as required by the policy and his coverage lapsed. According to ReliaStar, Dr. Tunkle regained his coverage in May, but because he received treatment for his tremor in the three months prior to the date of his restarted coverage, his tremor was a preexisting condition under the policy and thus ReliaStar refused to pay his claim. Dr. Tunkle appealed, arguing that he had voluntarily reduced his salary during the pandemic to keep the practice afloat, and that he had in fact worked more hours than the reports showed. ReliaStar denied Dr. Tunkle’s appeal, contending that he did not produce sufficient documentation to support his claims. Dr. Tunkle then filed this action, and the case proceeded to cross-motions for summary judgment, which were decided in ReliaStar’s favor. (Your ERISA Watch covered this decision in our August 14, 2024 edition.) Dr. Tunkle appealed to the Eleventh Circuit, which issued this per curiam decision. The court reviewed the district court’s grant of summary judgment de novo, but, like the district court, applied the arbitrary and capricious standard to ReliaStar’s decision because the policy gave ReliaStar discretion to review claims. Dr. Tunkle contended that “ReliaStar’s decision was arbitrary and capricious because his productivity report, payroll records, and letters prove that ReliaStar had no reasonable basis to conclude that he worked for fewer than thirty hours per week.” However, the Eleventh Circuit agreed with ReliaStar for two reasons. First, “Dr. Tunkle’s productivity report and payroll records reasonably support that he lost coverage because neither reflects thirty or more hours of weekly work between March 15 and May 23, 2020.” Second, “21st Century Oncology told ReliaStar that Dr. Tunkle’s payroll records and productivity report were its only records of his hours and that all his hours were recorded. 21st Century Oncology also asserted that it lacked ‘any information to support Dr. Tunkle working full time’ between mid-March and mid-May.” The court acknowledged that “[s]ome record evidence supports a contrary conclusion,” such as Dr. Tunkle’s explanation for his salary reduction and assertions of undocumented work. However, this was insufficient to overcome the deferential standard of review because “the record reasonably supported” ReliaStar’s decision, “regardless of whether the record also supported a different conclusion.” As a result, the court concluded that ReliaStar had a reasonable basis to determine that Dr. Tunkle lost his coverage in March 2020 when his weekly hours decreased, and his coverage did not restart until May 24, 2020. This meant that the preexisting condition provision applied and ReliaStar correctly denied Dr. Tunkle’s claim. Finally, the court considered whether ReliaStar operated under a conflict of interest, but because Dr. Tunkle “‘does not dispute’ that ReliaStar ‘was not operating under a conflict of interest,’” the court’s analysis ended there and the judgment below was affirmed.

Discovery

Eighth Circuit

Gibson v. Unum Life Ins. Co. of Am., No. 25-CV-2711 (JWB/JFD), 2026 WL 172541 (D. Minn. Jan. 22, 2026) (Magistrate Judge John F. Docherty). This action arises from defendant Unum Life Insurance Company of America’s denial of plaintiff Tyrone Gibson’s claim for long-term disability benefits. Gibson alleged two claims for relief under ERISA: one for plan benefits and another for equitable relief under the theory of surcharge for harm caused by Unum’s breaches of fiduciary duty. Before the court was Gibson’s motion for discovery. Gibson sought information to support his second claim for breach of fiduciary duty, claiming that Unum lied about the opinions of his treating physicians. Gibson acknowledged that plaintiffs are typically not entitled to discovery beyond the administrative record in ERISA benefit cases, but contended that “because he alleges misrepresentations by Unum the administrative record alone cannot provide the information he needs to fully litigate his claim for breach of fiduciary duty.” Gibson specifically requested to conduct discovery regarding “1) a correct and full record of the conversation between his treating physician and the Unum physician; 2) whether the Unum physician lied about that conversation; 3) why Unum relied on the Unum physician after Mr. Gibson raised his concerns about the alleged lie; 4) a full understanding of the qualifications of the nurse who opined on Mr. Gibson’s condition; and 5) whether Unum ‘compl[ied] with its obligations under the Regulator Settlement Agreement.’” Unum responded that “Mr. Gibson’s claim for breach of fiduciary duty is duplicative of his claim for benefits owed and is not a legitimate claim but an impermissible end-run around ‘ERISA’s goal of inexpensive and expeditious resolution of claims.’” Relying on recent decisions from within the district, the court ruled for Gibson, concluding that “a Plaintiff asserting a breach of fiduciary duty claim, alongside a separate claim for payment of benefits under ERISA, is entitled to discovery beyond the administrative record.” (The court noted that Unum failed to cite these decisions to the court, even though it was a party in one of those cases, had the same defense counsel, and made “indistinguishable” arguments in both.) The court “agrees with Mr. Gibson and other courts in this District that such misrepresentations would not have been recorded by Unum in the administrative record.” The court noted that it “of course expresses no view on the merits of the breach of fiduciary duty claim as this case goes forward. In fact, the Court has hesitations about the viability of a breach of fiduciary duty claim where such a claim alleges the denial of the claim itself as its sole basis.” However, “a court can find a claim well-pleaded and still entertain skepticism about the likelihood of success on that claim at trial.” As a result, “discovery beyond the administrative record is appropriate here.” Thus, the court granted Gibson’s motion and directed the parties to meet and confer and submit a proposed amended pretrial scheduling order.

Medical Benefit Claims

Ninth Circuit

Clove v. Teamsters Local 631 Security Fund for S. Nev., No. 2:24-CV-02348-APG-DJA, 2026 WL 146490 (D. Nev. Jan. 18, 2026) (Judge Andrew P. Gordon). Craig L. Clove is a retired former member of Teamsters Local 631 who argues in this action that the Teamsters’ Security Fund failed to notify him that he could retain health insurance benefits under the Fund’s benefit plan at a reduced rate after retiring. Clove’s last day of work for a contributing employer was in 2018, and he retired in April of 2021, after which the Teamsters’ pension plan approved him for a pension. In January of 2024, Clove applied to the Fund to participate in the retiree program for health care coverage, but his application was denied by the Fund on timeliness grounds. Clove appealed, and the Fund denied his application again, this time adding that he was ineligible for the benefit he sought because he did not work sufficient hours for contributing employers. Clove then filed this action. The Fund moved to dismiss, and both parties filed motions for summary judgment. The court reviewed the Fund’s decision for abuse of discretion because the plan gave the trustees discretionary authority to determine benefit eligibility. The court found there was no conflict of interest affecting this review because the Fund was administered by a joint labor-management board and funded by employer contributions that could not revert to the employers. However, the court noted a procedural irregularity because the Fund introduced a new reason for denial (Clove’s ineligibility) in its final decision, so the court weighed this in its abuse of discretion analysis. This irregularity was insufficient, however, as the court concluded that the Fund did not abuse its discretion in denying Clove’s claim. The court found that the plan “clearly and unambiguously” stated that a retiree was only eligible if the “Contributing Employer for whom the Retiree worked has contributed to the Plan (minimum 500 hours per year or equivalent) on behalf of the Retiree as an Employee for at least five (5) of the last seven (7) years immediately preceding retirement.” However, “[t]he evidence shows that Clove has not met this requirement because he has only four years of 500 contribution hours in the seven years preceding his retirement.” As a result, “Even considering the procedural irregularity, the Fund did not abuse its discretion in determining that Clove is ineligible.” Clove complained about inadequate notice from the Fund, but the court found this argument irrelevant, because the Fund clearly told him why he was ineligible, and “[e]ven if the Fund was required to give Clove notice of the eligibility requirements and did not do so, he would not meet those requirements.” As a result, the court granted the Fund’s motion for summary judgment, denied Clove’s motion, and denied the Fund’s motion to dismiss as moot.

Delgado v. ILWU-PMA Welfare Plan, No. 24-1845, __ F. App’x __, 2026 WL 161403 (9th Cir. Jan. 21, 2026) (Before Circuit Judges Wardlaw, N.R. Smith, and Miller). This case involves multiple plaintiffs who are participants in the ILWU-PMA Welfare Benefit Plan, a multiemployer health plan governed by ERISA. The plaintiffs all received treatment at Advanced Pain Treatment Medical Center (APTMC), a physician-owned surgery facility in San Pedro, California. Prior to January 1, 2013, the plan consistently paid facility fees for surgical procedures at APTMC, but after that date the plan stopped paying such fees, determining that APTMC was not a “hospital” as that term was defined by the plan. Plaintiffs brought this action under 29 U.S.C. § 1132(a)(1)(B), alleging that this decision was incorrect. The case proceeded to a bench trial, after which the district court ruled in favor of the plan, concluding that the plan’s trustees and the reviewing arbitrator did not abuse their discretion in determining that APTMC was not a “hospital.” Plaintiffs appealed, and in this memorandum disposition the Ninth Circuit reversed. The court first addressed the standard of review, and found that the district court correctly applied an abuse of discretion standard, as the plan conferred discretionary authority to the trustees. The court further found that plaintiffs did not demonstrate any procedural irregularities or conflicts of interest that would necessitate altering this standard of review. The court then addressed the merits and ruled that the district court erred in concluding that APTMC was not a “hospital.” The plan defined “hospital” to include a “licensed non-Medicare approved ambulatory surgical facility” that met specific criteria. However, the plan did not define “ambulatory surgical facility” or specify the type of license a facility must have. The court noted that the State of California no longer issues licenses for physician-owned surgical clinics and instead requires accreditation by an approved agency. APTMC was accredited to perform outpatient surgery. The court stated, “We do not understand the Plan to argue that APTMC fails to qualify as a ‘licensed’ facility solely because it lacks a license that California no longer issues.” The district court ruled that APTMC was not a licensed ambulatory surgical facility because its accreditor classified it as an “office-based surgery/procedure center,” but the Ninth Circuit agreed with plaintiffs that “this distinction has no significance in California law and does not affect the applicable accreditation standards. Neither category mirrors the exact term used in the Plan. Even under the abuse-of-discretion standard, it was error to define the term ‘ambulatory surgical facility’ solely by reference to a seemingly arbitrary distinction in the accreditor’s classification system.” As for a remedy, the Ninth Circuit noted that the district court did not make findings regarding other criteria defining the plan’s definition of “hospital,” and thus it declined to do so in the first instance. The court noted that these findings “will require close review of the extensive record, a task that we generally entrust in the first instance to the district court.” Thus, the Ninth Circuit remanded for further proceedings. Judge N. Randy Smith dissented, however. He argued that the majority failed to properly apply the standard of review and that the Trustees did not abuse their discretion in determining that APTMC was not a “hospital.” Judge Smith argued that three of the four criteria of the Plan definition of “hospital” were not met by APTMC, and that “the Plan provides no definition as to what an ‘ambulatory surgical facility’ is, thus leaving it to the Trustees’ discretion to determine its meaning.” Because of “the Plan’s complete lack of instruction as to what constitutes an ‘ambulatory surgical facility,’ and an abuse of discretion standard for making this determination on appeal, the majority cannot show how the Trustee’s determination ‘clearly conflicts with the plain language’ of the Plan.” As a result, Judge Smith would have affirmed the decision below. (Disclosure: Kantor & Kantor LLP is counsel of record for plaintiffs in this action.)

Eleventh Circuit

Vickie B. v. Anthem Blue Cross & Blue Shield, No. 1:25-CV-3054-MLB, 2026 WL 146545 (N.D. Ga. Jan. 20, 2026) (Judge Michael L. Brown). Plaintiff Vickie B. is a participant in the self-funded Bank of America Group Benefits Program, and her son, D.B., is also insured under the plan. Anthem Blue Cross and Blue Shield is the third-party claims administrator for the plan. D.B. has a history of anxiety, ADHD, and drug and alcohol abuse, which led to his admission to Wingate Wilderness Therapy in February 2022. Wingate is a treatment facility in Utah that provides sub-acute treatment to adolescents with mental health, behavioral, and substance abuse problems. Anthem denied payment for D.B.’s treatment at Wingate, claiming it was not a covered service under the plan. In May 2022, D.B. was admitted to Crossroads Academy, another treatment facility in Utah, where he received mental health, behavioral, and substance abuse treatment. Anthem initially denied payment for this treatment because Vickie did not seek preapproval for the benefit, and later stated D.B.’s treatment at Crossroads did not meet the plan’s medical necessity requirements for residential mental health treatment. Vickie then brought this action against Blue Cross and the plan alleging two claims for relief under ERISA: one for plan benefits under Section 1132(a)(1)(B), and one under Section 1132(a)(3) for violation of the Mental Health Parity and Addiction Act of 2008 (Parity Act). Defendants moved to partially dismiss the complaint, seeking dismissal of all claims except Count I regarding D.B.’s Crossroads treatment. First, defendants contended that Wingate was an “alternative residential program” not covered by the plan. Plaintiffs responded that Wingate’s services were covered because the language defining covered mental health and chemical dependency services is “inclusive rather than exclusive.” The court found this argument “puzzling” because it ignored the definition of an approved treatment facility. Plaintiffs also argued that the plan defines a treatment facility as one that only deals with substance abuse issues, and because D.B. received both substance abuse and mental health treatment, the facility requirements did not apply. However, the court found that the plaintiffs cited the wrong definition of “treatment facility,” and regardless, “even without a specific definition in that section of the Plan, Wingate fits comfortably within the ‘plain and ordinary meaning’ of a treatment facility.” Plaintiffs further alleged that Wingate was an “outdoor behavioral health program” rather than a “wilderness camp,” but the court found that this was a distinction without a difference for the purposes of the plan. Finally, plaintiffs argued that the plan’s requirement of 24-hour nursing and an onsite psychiatrist was “not consistent with generally accepted [sic] at outdoor behavioral health providers,” However, the court stated that this “seems more like an argument that the terms of the Plan are unfair rather than an argument that Defendant misapplied or misinterpreted the plan.” Thus, the court concluded that Wingate fell within the plan’s exclusion and did not meet the plan’s requirements for coverage. Plaintiffs had more luck with their Parity Act claim, however. Defendants contended that this claim was duplicative of plaintiffs’ claim for benefits, but the court disagreed, ruling that plaintiffs’ two claims were not based on the same underlying conduct and did not rely on similar allegations. “Plaintiffs’ allegations in [the first] count concern Defendants’ application of the Plan’s requirements for coverage of D.B.’s treatment at Wingate and Crossroads… In Count II, however, they shift their allegations and focus to the substance of the Plan’s coverage requirements themselves[.]” As a result, “Plaintiffs’ Section 1132(a)(1)(B) and Section 1132(a)(3) claims can comfortably coexist.” The court further found that plaintiffs’ Parity Act claim properly sought equitable relief and was not merely “cloaking the relief sought in equitable language.” As for the merits of the Parity Act claims, the court rejected plaintiffs’ claim against Wingate, (1) ruling that plaintiffs irrelevantly cited to billing codes, (2) noting that “the Plan does not categorically exclude outdoor behavioral health and wilderness programs,” and (3) finding that plaintiffs’ allegations regarding analogous medical/surgical facilities were conclusory and belied by plan language. As for Crossroads, the court found that plaintiffs failed to identify the specific medical necessity criteria used for analogous medical or surgical treatment, rendering their allegations of disparity conclusory. The court allowed plaintiffs to replead this claim, however, because they did not have the criteria at the time they filed their complaint. Finally, plaintiffs alleged that defendants violated the Parity Act by failing to provide a comparable degree of in-network residential treatment facilities compared to in-network skilled nursing and inpatient rehabilitation facilities. However, the court found that plaintiffs lacked standing to assert this claim, as they did not “explain the causal connection between Defendants’ alleged network inadequacy and the denial of benefits at Wingate or Crossroads.” In the end, the court granted in part and denied in part defendants’ motion, allowing plaintiffs to amend Count II of their complaint to reallege their Parity Act claim against Crossroads, while dismissing Counts I and II as to Wingate.

Provider Claims

Second Circuit

Long Island Plastic Surgical Grp., PC v. UnitedHealthcare Ins. Co. of N.Y., No. 21-CV-5825(JS)(ST), 2026 WL 161152 (E.D.N.Y. Jan. 21, 2026) (Judge Joanna Seybert). In this action Long Island Plastic Surgical Group, P.C. asserted seven claims against UnitedHealthcare Insurance Company of New York arising from non-payment for plaintiff’s treatment of patients insured by United. Before the court was plaintiff’s motion for leave to amend its complaint. In August of 2025 a magistrate judge issued a report and recommendation (R&R) suggesting the court grant in part and deny in part plaintiff’s motion. Specifically, the magistrate ruled that plaintiff’s ERISA benefits claim was valid for plans without anti-assignment provisions, but not for those with such provisions, and that plaintiff’s unjust enrichment claim was preempted by ERISA. Both parties objected, and in this order the district court mostly overruled the objections. On its claim for ERISA plan benefits, plaintiff objected to the dismissal of claims with anti-assignment provisions, contending that it is “plausible that the health plans’ actions waived the anti-assignment clauses or estopped the plans from asserting them.” The court noted that plaintiff’s counsel had “lodged an objection in another case before this Court just two months ago that is identical to the above objection, save for changes to the names of the parties and citations[.]” The court overruled the plaintiff’s objection in that case, and did the same here, ruling that there was no “clear intent” by United to waive its rights under the anti-assignment clause; simply participating in the claims administration process was insufficient. The court also overruled plaintiff’s objection regarding its unjust enrichment claim, ruling that it was preempted by ERISA. As for defendants’ lone objection, the court overruled it, upholding the R&R’s determination that plaintiff had properly alleged that it had assignments from its patients to assert their ERISA claims because the assignments “conveyed ownership.” In doing so, the court distinguished a Second Circuit case relied on by defendants (Cortlandt St. Recovery Corp. v. Hellas Telecomm., S.a.r.l., 790 F.3d 411 (2d Cir. 2015)), noting that it was not an ERISA case and was inconsistent with other Second Circuit precedent regarding the assignment of benefits in the ERISA context. In the end, the court overruled all of the objections by the parties except for plaintiffs’ objection regarding its state law claim for unjust enrichment claim relating to emergency services, which was sustained. The court ordered plaintiff to file a second amended complaint consistent with this order by February 4.

Rowe Plastic Surgery of N.J., LLC v. Aetna Life Ins. Co., No. 23CV7049 (DLC), 2026 WL 158610 (S.D.N.Y. Jan. 20, 2026) (Judge Denise Cote). Regular readers of Your ERISA Watch are familiar with Rowe Plastic Surgery of New Jersey, which has filed numerous actions against insurers asserting breach of contract and other claims relating to non-payment or underpayment for treatment it provided to patients. As the court noted, “The complaint filed in this lawsuit is identical in all material respects to a score of such complaints filed by Rowe in this district and in the Eastern District of New York.” In this case, defendant Aetna Life Insurance Company originally filed a motion to dismiss in 2023, but the action was stayed pending a decision by the Second Circuit in one of Rowe’s other cases. After the ruling in that case, Rowe moved to amend its complaint and the magistrate judge recommended that the motion be denied. Rowe objected, and the court considered both Aetna’s motion to dismiss and Rowe’s objections in this order. The court was not pleased with Rowe: “As several judges have warned Rowe and its counsel, their continued litigation – in a raft of lawsuits of virtually identical claims which have been repeatedly dismissed – risks the imposition of sanctions. That remains true.” (Your ERISA Watch detailed Judge Colleen McMahon’s irritation with Rowe in another case – in which she called Rowe’s arguments “frivolous” and “ridiculous” and threatened sanctions – in our March 12, 2025 edition.) The court ruled that Rowe’s amended complaint was essentially identical to its previous versions: “All of these claims rely on a May 14, 2021 call and the statement by an Aetna employee that Aetna’s payment for the procedure would be calculated using the ‘80th percentile of reasonable and customary.’ As courts have repeatedly held, this conversation did not create a contract and did not constitute a promise to pay a particular sum. It was a benefits verification call.” The court then quickly rejected Rowe’s other state law claims on various grounds. Finally, the court noted that “Rowe in essence seeks to stand in the shoes of its surgical patients and to challenge the ERISA benefits that are provided to those patients. Its state law claims allege an ‘improper processing of a claim for benefits,’ and ‘undoubtedly meet the criteria for pre-emption’ under ERISA’s express preemption clause… On this separate ground, Rowe’s claims are preempted and must be dismissed.” As a result, the court granted Aetna’s motion to dismiss, denied Rowe’s motion to amend, overruled Rowe’s objections, and entered judgment in Aetna’s favor.