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Peter Sessions

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Peter S. Sessions is a partner at Kantor & Kantor who has been with the firm since 2004. Peter represents individual clients seeking health, life, and disability benefits, typically under employee health plans.

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Good morning, ERISA Watchers!  I hope this finds you well and in good spirits.  This week’s notable decision, Wallace v. Oakwood Healthcare, Inc., No. 18-2316, __F.3d__, 2020 WL 1522833 (6th Cir. Mar. 31, 2020), involves something we might all be feeling these days: exhaustion.  

Wallace involves a challenge to a denied long-term disability benefit claim.  Plaintiff was a registered nurse who was a participant in an ERISA-governed employee welfare benefit plan sponsored by her employer (“the Plan”). She stopped working in 2012 while the Plan was insured by Hartford Life & Accident Insurance Company. On January 1, 2013, the Plan shifted its contract to Reliance Standard. Plaintiff tried to return to work in 2013, but quickly went back on medical leave. She subsequently submitted a claim for benefits to Reliance, who denied it on the ground that she had a pre-existing condition that barred coverage. Plaintiff also submitted a claim to Hartford, who denied that as well. She appealed the Hartford denial, but did not appeal the Reliance denial before filing suit against Reliance.
Continue Reading Sixth Circuit Holds Exhaustion of Administrative Remedies Not Required Where Plan Document Is Silent on Claims Review Process

This week’s notable decision is North Cypress Med. Ctr. Operating Co., Ltd. v. Cigna Healthcare, No. 18-20576, __ F.3d __, 2020 WL 1291590 (5th Cir. Mar. 19, 2020), where the Fifth Circuit, in the case’s second trip to the Court of Appeals, ruled in favor of Cigna in its dispute with an out-of-network healthcare provider.

This is an action by a hospital against Cigna for the alleged underpayment of more than $40 million in benefit claims assigned to the hospital by Cigna insureds. The dispute revolved around North Cypress’ billing approach. In order to encourage prompt payment by its patients, the hospital offered to reduce the patients’ coinsurance obligations—even if their treatment was out-of-network—if they paid a certain amount of their bill within 120 days. Under this approach, out-of-network patients received a significant discount, North Cypress incurred lower collection costs, and meanwhile Cigna’s payment obligation remained the same.
Continue Reading Fifth Circuit Rules in Favor of Cigna in Dispute with Out-of-Network Provider Over Patients’ Coinsurance Obligations

Retired steelworkers and their families have something to be thankful for this week.  And no, it’s not turkey.  This week’s notable decision is Stone v. Signode Industrial Group LLC, No. 19-1601, __ F.3d __, 2019 WL 6139680 (7th Cir. Nov. 20, 2019), where the Seventh Circuit held that Signode Industrial Group LLC’s successors were obligated to continue to provide benefits to retirees even after the employer’s termination of the underlying collective bargaining agreement.  

Defendant Signode was the sponsor of a health care benefit plan for retired steelworkers, the terms of which it had negotiated with a union. Defendant terminated the underlying benefits agreement and ceased paying benefits to the retirees and their families. Plaintiffs initiated a class action under both ERISA and the Labor-Management Relations Act contending that benefits under the plan were vested and thus could not be terminated. On cross-motions for summary judgment, the district court (Judge Thomas M. Durkin, N.D. Ill.) granted Plaintiffs’ motion and denied Defendants’ motion, holding that Defendant did not have the right to terminate benefits. The district court entered a permanent injunction against Defendants, who appealed.
Continue Reading Seventh Circuit Holds Employer to Promise of Lifetime Health-care Benefits for Retirees