We at Your ERISA Watch do not know whether it was the ongoing federal government shutdown, the captivating seven-game World Series between the Dodgers and Blue Jays, or simply the always-jarring transition away from daylight saving time (or is it daylight “savings” time?), but it was another slow week for the federal courts in ERISAland. As a result, there was no stand-out notable decision to break down.

The courts soldiered on, however, so keep reading to learn about another blow to class actions based on forfeited employer contributions to retirement plans (Polanco v. WPP Group), two decisions on motions to dismiss in class actions challenging excessive recordkeeping fees (Gosse v. Dover Corp. and Milano v. Cognizant), the easiest life insurance interpleader case of all time (Kostomite v. Kimberley-Clark), and, if you are especially sleepy, an expedition into the fascinating world of Colorado River abstention (Gray v. Arrow). We’ll see you next week!

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

Breach of Fiduciary Duty

Second Circuit

Polanco v. WPP Group USA, Inc., No. 24-cv-9548 (JGK), 2025 WL 3003060 (S.D.N.Y. Oct. 27, 2025) (Judge John G. Koeltl). Plaintiffs Rafael Polanco and Monique Johnson are participants in a defined contribution plan sponsored by their former employer WPP Group USA, Inc. and administered by the plan’s Administrative and Investment Committee. Plaintiffs allege that WPP and the Committee breached their fiduciary duties and engaged in prohibited self-dealing in violation of ERISA by using forfeitures to reduce employer contributions rather than to defray the plan’s administrative costs. Defendants filed a motion to dismiss the complaint. The court granted that motion in this decision. It broke down the claims one by one. First, the court dismissed the claim of disloyalty. It concluded that plaintiffs could not maintain this cause of action for three reasons: (1) it interprets the duty of loyalty to create a benefit that the plan document itself does not guarantee – the use of forfeitures to pay administrative expenses; (2) it rests on a faulty assumption that plan participants would receive greater benefits if defendants used the forfeitures to cover administrative expenses because the plan document does not require WPP to make employer contributions at all; and (3) plaintiffs’ theory of disloyalty is difficult to harmonize with established practice, including the Treasury Department’s regulations which permit employers to use forfeitures to cover employer contributions. In sum, the court concluded that defendants complied with the terms of the plan and provided the plan participants with their benefits due, and as a result, granted the motion to dismiss the claim for breach of the duty of loyalty. Next, the court dismissed plaintiffs’ claim that defendants utilized an imprudent and flawed process in how to allocate forfeitures. To the extent that this claim was based on defendants’ particular decision-making process, the court found the complaint’s allegations “too conclusory to establish a plausible entitlement to relief,” and to the extent it is based on a broader theory that the duty of prudence requires defendants to use the forfeitures to pay administrative costs, the court found that this idea was “contrary [to] the settled understanding of Congress and the Treasury Department regarding defined contribution plans like the one at issue in this case.” The court also dismissed the duty to monitor claim against WPP. It stated that plaintiffs could not maintain such a cause of action because their two underlying fiduciary breach claims of disloyalty and imprudence against the Committee were found to be insufficient and implausible. Finally, the court dismissed plaintiffs’ prohibited transactions claims under 29 U.S.C. § 1106(a)(1) and (b)(1). It found that plaintiffs failed to adequately state claims under either subsection “because using forfeitures to cover employer contributions is not a transaction within the meaning of those provisions.” Instead, the court agreed with defendants that the intra-plan reallocation of forfeitures to cover employer contributions is a “payment of benefits and thus not a transaction within the meaning of § 1106.” Accordingly, the court granted defendants’ motion to dismiss the entirety of plaintiffs’ action. The court dismissed the prohibited transaction claims with prejudice, but dismissed the fiduciary breach claims with leave to amend.

Seventh Circuit

Gosse v. Dover Corp., No. 22 C 4254, 2025 WL 2996795 (N.D. Ill. Oct. 24, 2025) (Judge LaShonda A. Hunt). This putative class action was brought by two participants of the Dover Corporation 401(k) plan against the plan’s fiduciaries alleging that they breached their duties under ERISA by paying excessive recordkeeping fees to third-party administrators Wells Fargo and Merrill Lynch. Defendants moved to dismiss for failure to state a claim. The court granted the motion and dismissed the complaint with prejudice in this decision. As it had in earlier decisions, the court found that plaintiffs’ amended complaint “was closer to [the Seventh Circuit’s decision in] Albert than Hughes II, primarily because the facts alleged therein did not offer an apples-to-apples comparison of comparable services or plans.” Specifically, the court took issue with the complaint’s failure to show that the cited plans were comparable to the Dover plan in terms of asset size, services provided from the recordkeepers, or the methods for calculating total fees. The underlying message was that plaintiffs failed to plead enough factual content to render it plausible that the fiduciaries incurred unreasonable recordkeeping and administrative fees and failed to take actions to lower such expenses. Accordingly, after engaging “in the context-specific scrutiny required by Hughes II,” the court concluded that it could not infer fiduciary wrongdoing from the allegations in the amended complaint, and for this reason, the court granted defendants’ motion to dismiss.

Class Actions

Second Circuit

Lloyd v. Argent Trust Co., No. 22cv4129 (DLC), 2025 WL 3041911 (S.D.N.Y. Oct. 31, 2025) (Judge Denise L. Cote). The participants of the W BBQ Holdings, Inc. Employee Stock Ownership Plan moved for class certification in their ERISA lawsuit challenging the plan’s 2016 stock transaction and the events that led up to it. In this short decision, the court granted the motion. As an initial matter, the court held that the class is ascertainable as it consists of plan members who can easily be identified through objective criteria. The court also explained that the class satisfies the requirements of Rule 23. Beginning with Rule 23(a), the court concluded that the class of well over a thousand members is sufficiently numerous, that there are common questions of law and fact shared among the class, “such as whether the defendants violated their fiduciary obligations and whether the ESOP paid a fair price for its purchase of W BBQ stock,” plaintiffs’ claims are typical of the other class members, and plaintiffs and their attorneys at Cohen Milstein Sellers & Toll PLLC are adequate representatives of the class. Turning to certification under Rule 23(b), the court concluded that certification under subsection 23(b)(1)(B) is appropriate because “the success or failure of claims by any class members will greatly impact the claims of other members.” Accordingly, the court saw no impediment to certification and therefore certified the proposed class. Moreover, the court appointed the named plaintiffs Jamal Lloyd and Anastasia Jenkins as class representatives and Cohen Milstein as class counsel.

Discovery

Sixth Circuit

Nationwide Children’s Hospital v. The Raymath Co., No. 3:23-cv-00044, 2025 WL 3022504 (S.D. Ohio Oct. 29, 2025) (Magistrate Judge Caroline H. Gentry). This dispute arises from The Raymath Company Health Plan’s non-payment of $561,379.41 worth of medical claims that plaintiff Nationwide Children’s Hospital submitted for care it provided to a minor child who was a beneficiary of the plan. In this lawsuit Nationwide challenges the non-payment of its claim for benefits under both ERISA and state law, the claim processing procedures used by third-party administrator J.P. Farley Corp., and the failure to submit Nationwide’s claim for benefits under a policy of stop-loss coverage provided by the Excess Reinsurance Underwriters Agency. Toward the end of the discovery period, J.P. Farley Corp. and Nationwide issued deposition subpoenas to non-party Michael Kerns in connection with his company’s sale of the stop-loss insurance policy to Raymath and the ways in which he is alleged to have intervened in the processing of Nationwide’s claim for benefits to prevent it from being submitted for stop-loss coverage, as he would have suffered a personal financial loss if the claim was submitted. Not wanting to be deposed, Mr. Kerns moved to quash the subpoenas. The court denied his motion in this decision. It held that Mr. Kerns did not show that being required to testify at a deposition would subject him to an undue burden, and instead found the proposed line of questioning both relevant and proportional. It stated, “[b]ased upon the parties’ discussions of the evidence obtained during discovery, Kerns appears to have personal knowledge about several issues that are of central importance to the parties’ claims and defenses. Although Kerns argues that his financial interests are irrelevant, the Court disagrees because the parties contend that a financial conflict of interest motivated him to intervene in the processing of Nationwide’s claim. Finally, the parties have no other way to obtain the information that they seek. For all of these reasons, the likely benefit of deposing Kerns strongly outweighs the slight burden of being required to testify at a deposition.” The court did not take kindly to Mr. Kerns’ primary argument that it should prohibit or limit his deposition because the parties seek to obtain evidence that can be used against him. It found this proposition “startling,” not supported by “any authority,” and “readily refuted,” given that “Rule 45 does not allow non-parties to quash or modify subpoenas to avoid being required to implicate themselves or admit to wrongful conduct. To the contrary, non-party deposition subpoenas may be used for precisely that purpose.” In sum, it was abundantly clear to the court that Mr. Kerns’ deposition is necessary and thus it denied his motion to quash in its entirety.

Exhaustion of Administrative Remedies

First Circuit

Gray v. Arrow Mutual Liability Ins. Co., No. 25-10054-NMG, 2025 WL 3033882 (D. Mass. Oct. 29, 2025) (Judge Nathaniel M. Gorton). Plaintiffs Susan C. Gray and Brian Gray are the wife and son of decedent Peter Gray. In this action the mother and son allege that defendants Arrow Mutual Liability Insurance Company, the Arrow Mutual 401(k) Plan, and Tanya Ucuzian violated ERISA by wrongfully withholding over $600,000 in employer contributions when they distributed the plan assets to the family. In their lawsuit plaintiffs assert claims against defendants for wrongful denial of benefits under Section 502(a)(1)(B), equitable relief under Section 502(a)(3), and violation of ERISA Section 510. Defendants moved to dismiss all claims, or in the alternative, to stay the case pending resolution of the state court action in which the parties are currently involved which also concerns, among other things, Peter’s participation in the 401(k) plan. In this order the court denied the motion to dismiss, but allowed the motion to stay pending resolution of the state court action, which is much further along and set to go to trial in March. The court’s discussion of the pending motion to dismiss mostly focused on the issue of exhaustion. It decided without much ado that Susan exhausted all available administrative remedies before commencing the present action. “The complaint, as well as defendants’ own submissions, make clear that Susan filed a claim for benefits in December, 2023, when she submitted the Death Benefit Claim 401(k) Plan form. In November, 2024, Susan sent a letter to defendants reiterating that original claim. Defendants denied the claim with respect to employer contributions in February, 2025, more than one year after the original claim was made and almost two months after the filing of the present action. That delay is sufficient, as per regulation, to consider Susan’s administrative remedies exhausted.” However, the court agreed with defendants that the state law action and the federal action are sufficiently parallel to warrant a stay since both lawsuits cover similar ground concerning whether Peter was a valid member of the 401(k) plan. Thus, the court found that the claims here overlap with some of the claims in the state court proceedings and that the state court’s conclusions will have some bearing on whether plaintiffs are entitled to relief under ERISA. Consequently, the court concluded that it is prudent to stay the federal case pending resolution of the case in Essex County, Massachusetts.

Medical Benefit Claims

Second Circuit

Marc Everett MD PC v. UMR, Inc., No. 22-CV-4856 (ARR) (AYS), 2025 WL 3004944 (E.D.N.Y. Oct. 27, 2025) (Judge Allyne R. Ross). Plaintiff Marc Everett M.D. brought this action on behalf of his patient against defendant UMR, Inc. under ERISA Section 502(a)(1)(B) alleging that it underpaid healthcare benefits for a bilateral breast reduction surgery that was covered under the plan. The parties filed cross-motions for summary judgment under an arbitrary and capricious standard of review. Because the court agreed with Dr. Everett that UMR’s $2,132.54 payment based on 150% of Medicare rate did not conform with the Summary Plan Description’s general definitions of “Reasonable Reimbursement” and “Usual and Customary” for out-of-network providers, the court granted summary judgment in favor of Dr. Everett. In addition to finding that the language of the plan did not support the administrator’s benefit determination, the court also concluded that the other materials in the administrative record suggested that the use of the Medicare rate was an abuse of discretion. In fact, the court said that nothing within the administrative record supported the idea that the reimbursement was to be based on 150% of Medicare rate. To the contrary, the court agreed with Dr. Everett that UMR’s “threadbare interpretation of the Plan” was arbitrary and capricious. Accordingly, the court granted Dr. Everett’s motion for summary judgment, while it denied UMRs motion. This left only the issue of how to remedy the plan administrator’s abuse of discretion. Ultimately, relying on Second Circuit precedent, the court concluded that the appropriate remedy was to remand the claim back to UMR for UMR to interpret “usual and customary” based on the prevailing market rates for the procedure in the relevant geographical area.

Pension Benefit Claims

Third Circuit

Kostomite v. Kimberley-Clark Corp., No. 24-4473, 2025 WL 3002995 (E.D. Pa. Oct. 27, 2025) (Judge Gail Weilheimer). Plaintiff Sophie Kostomite brought this lawsuit as the beneficiary of her long-time partner Bill Teetsel’s 401(k) & Profit Sharing Plan account. Although the couple was not legally married, Ms. Kostomite often used her partner’s surname, Teetsel, as her own, so much so that Bill Teetsel named “Sophie Teetsel” as his designated beneficiary. The social security numbers and dates of birth of Sophie Teetsel and Sophie Kostomite match exactly. Thus, identifying herself as the named beneficiary, plaintiff submitted a claim for benefits under the plan following Bill’s death. While many cases present close calls and difficult determinations, the court was adamant that this was not one of them. Instead, it stated that this case was so clear that “it is puzzling as to how we arrived at a point where the judicial power of the United States is required to resolve it.” The court found “it inescapably obvious that the Decedent intended to name Plaintiff the recipient of the Plan’s proceeds. The use of her social security number and birth date makes it entirely unambiguous that the Decedent intended the Plan’s funds to go to Plaintiff. That misuse of the last name Teetsel creates virtually no ambiguity in the face of that corroboration. The only logical conclusion that can be drawn from this set of facts is that the Decedent, in his own mind, thought of Plaintiff as his spouse and referred to her as having his name. This is particularly true in light of the record evidence which shows that Plaintiff at least sometimes used Teetsel as her last name, and that she and Decedent were live-in romantic partners across decades. There is no other reasonable way to understand that beneficiary designation, and no reasonable jury could conclude otherwise.” In an attempt to thwart plaintiff’s claim to the benefits the Estate of Bill Teetsel offered a strange theory – that the identification was meant to be a qualifier or a requirement that in order to receive the funds, the couple needed to be married. This theory was offensive to the court. It disregarded this “rank speculation” for three reasons: (1) married spouses are automatically beneficiaries under the plan; (2) not all married women assume the last name of their spouses; and (3) there is no law which prevents Ms. Kostomite from legally changing her surname to Teetsel even without marrying Bill. For these reasons, the court flatly rejected defendant’s hypothesis that the plan’s designation was conditional. Instead, the court offered its own theory. It theorized that the Estate’s “whimsical alternative explanation” was simply a wild “attempt to gain a $300,000 windfall.” Seeing no genuine dispute of material fact that plaintiff and beneficiary were one and the same, the court entered judgment in favor of Ms. Kostomite, and awarded her the benefits her partner always intended for her to have.

Pleading Issues & Procedure

Third Circuit

Milano v. Cognizant Tech. Solutions U.S. Corp., No. 20-cv-17793 (MEF)(SDA), 2025 WL 3002178 (D.N.J. Oct. 27, 2025) (Judge Michael E. Farbiarz). Employees of Cognizant Technology Solutions U.S. Corporation sued the investment committee of the company’s 401(k) plan under ERISA alleging that it failed to control the administrative and recordkeeping expenses of the plan which left them saddled with unreasonable costs. Defendant moved to dismiss the complaint pursuant to Rule 12(b)(1). The investment committee presented the question of whether plaintiffs have standing under Article III to press their claims to the extent they are based on fees associated with plan funds that they did not personally invest in. The court could not say. The long and the short of it is that this decision functioned more as a vehicle for posing questions than for answering them. If the fees were paid on a uniform basis, the court was confident that plaintiffs do have standing. If, on the other hand, they were paid in a nonuniform manner through a revenue sharing model, the court was less certain. In the latter situation, it found the question to be a closer call, as there are several decisions, including within the Third Circuit, which suggest that the answer may potentially be no. Further complicating matters, it appears as though the Cognizant Tech 401(k) plan had a direct-fee model after September 2018 and an indirect-fee model before September 2018. Because the resolution of these Article III standing questions depends on factual and legal matters that have not been fully addressed by the parties, the court determined that there was simply “no way to thoughtfully resolve the Defendant’s motion to dismiss” just yet. Given this backdrop, the court denied the motion to dismiss without prejudice and ordered the parties to file briefing indicating how they wish to proceed.

Seventh Circuit

Whitten v. Midwest Refrigeration Corp., No. 2:24-CV-407-PPS-JEM, 2025 WL 3002978 (N.D. Ind. Oct. 23, 2025) (Judge Philip P. Simon). Plaintiff Kenneth Whitten worked for the Midwest Refrigeration Corp. (“Midwest”) for 36 years. According to Mr. Whitten, Midwest and his union entered into a collective bargaining agreement on September 25, 1989, that obligated Midwest to make pension contributions on his behalf and on behalf of other eligible employees. Mr. Whitten maintains that despite this obligation, Midwest did not begin remitting pension contributions on his behalf until eight years later. In this lawsuit Mr. Whitten alleges that those missing years of pension contributions were in violation of ERISA and state law. Midwest moved to dismiss the complaint pursuant to Rule 12(b)(6). Because the court agreed with Midwest that it is not a proper defendant for either Mr. Whitten’s ERISA claim for benefits or his ERISA claim for fiduciary breach, the court granted the motion to dismiss. Beginning with the Section 502(a)(1)(B) claim, the court held that Mr. Whitten could not sue Midwest because it was not the benefit plan itself, nor an entity that controls the plan. In fact, the court concluded that Mr. Whitten had alleged “no facts to plausibly suggest Midwest is sufficiently intertwined with his plan to state a Section 502(a)(1)(B) claim against it.” Moreover, the court determined that the Section 502(a)(3) claim also failed because there are no plausible allegations in the complaint to suggest that Midwest had any “authority, control, or discretion with respect to the benefit fund’s assets, administration, or management.” The court rejected the notion that Midwest exercised any control over the plan’s assets or functioned as a plan fiduciary simply by virtue of being a contributing employer. Nor did the court agree with Mr. Whitten that “Midwest’s partial payment of $23,538.20 to correct its shortfall in contributions demonstrates discretionary control over the fund and the administration of its contributions.” To the contrary, the court viewed this as demonstrating Midwest only exercised control over its own assets. Accordingly, the court granted the motion to dismiss both causes of action under ERISA. And, having found that the complaint fails to state its federal claims, the court declined to exercise supplemental jurisdiction over the remaining state law claim for breach of an oral agreement. As a result, the court granted Midwest’s motion to dismiss.

Remedies

Sixth Circuit

Chalk v. Life Ins. Co. of N. Am., No. 3:25-cv-133-RGJ, 2025 WL 3006758 (W.D. Ky. Oct. 27, 2025) (Judge Rebecca Grady Jennings). On April 24, 2024, plaintiff Jennifer Chalk submitted a claim for short-term disability benefits to Life Insurance Company of North America (“LINA”) relating to pain from the amputation of her right leg and adjustment to a prosthesis. LINA initially approved the claim. However, right before Ms. Chalk received the maximum short-term disability benefits, on October 16, 2024, LINA terminated them. While she was appealing this decision, Ms. Chalk submitted a separate claim to LINA for long-term disability benefits on October 30, 2024. The parties agree that Ms. Chalk submitted this claim for long-term disability benefits and that LINA failed to issue notice of its decision regarding the long-term disability claim within 45 days in violation of 29 C.F.R. § 2560.503-1(f)(3). There is also no dispute that Ms. Chalk is deemed to have exhausted her administrative remedies, and is entitled to sue for these benefits under Section 502(a)(1)(B), as she has done in this lawsuit. Rather, the dispute before the court was whether LINA should have the opportunity to decide the claim now despite its failure to conduct a review of it within ERISA’s statutory deadline. LINA believed so. It moved the court to order an administrative remand so it could consider the claim in the first instance, and for the case to be stayed pending that process. Ms. Chalk objected. She argued that remand is not an appropriate remedy because it would function as a reward for LINA’s inaction and would frustrate the purposes of ERISA. She further argued that the administrative record is sufficiently developed in this case because LINA already made a determination with respect to her claim under the short-term disability policy. Thus, she argued, the court should conduct a de novo review of her long-term disability claim and should decide the issue of disability based upon the information already developed. In addition, Ms. Chalk requested that even if the court grants LINA’s motion for remand, that it order LINA “pay [her] LTD benefits to date, continue to provide her benefits while they perform the claim review, and reimburse her attorneys’ fees and costs.” The court decided to order a remand. It agreed with LINA that the problem here was a procedural violation which prevented a full and fair review and that this failure resulted in an incomplete and insufficient administrative record regarding the long-term disability claim. Under these circumstances, the court concluded that case law supports remand. Accordingly, the court granted LINA’s request for an administrative remand, despite its violations of ERISA’s claims handling procedures, and ordered LINA to conduct a full and fair review of Ms. Chalk’s long-term disability claim under the policy. The court, however, denied LINA’s request for a stay. It held that this request was moot in light of this chosen remedy. Finally, the court ended its decision by expressing an openness to Ms. Chalk’s requests for damages including past-due benefits and attorneys’ fees and costs. Although it did not conclusively issue any rulings regarding these requests, it stated that there is at least the possibility that Ms. Chalk may be entitled to some or all of them. Accordingly, the court permitted her to file a more formal motion for attorneys’ fees and costs under Section 502(g)(1), as well as a more formal request for an award of benefits.

Venue

Sixth Circuit

Janosky v. United Surgical Partners International, Inc., No. 25-68-DLB-CJS, 2025 WL 3022319 (E.D. Ky. Oct. 29, 2025) (Judge David L. Bunning). This putative class action is a tobacco surcharge ERISA case brought against a corporate owner of hundreds of medical and surgical facilities, defendant United Surgical Partners International, Inc. Before the court was United Surgical’s motion to change venue, in which it sought to transfer the case to the Northern District of Texas, Dallas Division pursuant to 28 U.S.C. § 1406(a) and 28 U.S.C. § 1404(a). Plaintiff Dara Janosky, a resident of Kentucky, filed a response in opposition on behalf of herself and the putative nationwide class. In its order the court agreed with defendant that transfer to Texas is proper pursuant to both Sections 1406(a) and 1404(a). With regard to 28 U.S.C. § 1406(a), the court concluded that ERISA’s venue statute has not been satisfied because (a) the benefit plan at issue is administered in the Northern District of Texas, (b) United Surgical does not have minimum contacts with Kentucky (none of its 551 facilities are located in the state), and (c) each of the claimed breaches concerning the design and administration of the welfare plan took place in Dallas, not Kentucky. Furthermore, the court stated that even if it agreed that venue was legitimate in Kentucky under ERISA, transfer was warranted pursuant to 28 U.S.C. 1404(a). Weighing the factors, the court concluded that the convenience of witnesses, location of documents, locus of operative facts, availability to compel witnesses, and trial efficiency all weighed in favor of defendant. While the court did conclude that the relative means of the parties weighed slightly in favor of Ms. Janosky, this factor alone was not determinative. All of the remaining factors were considered neutral by the court, including the convenience of the parties, the forums’ familiarity with ERISA, and the weight accorded to plaintiff’s chosen forum. In sum, the court found that the relevant factors, when looked at as a whole, support transferring this case to the Northern District of Texas. In fact, the court stated that Ms. Janosky’s residence is the only connection to the state of Kentucky and noted that she works remotely for United Surgical in Ohio. Altogether, the court was convinced that defendant satisfied its burden to demonstrate that transfer was appropriate, and thus it granted the motion to change venue and ordered the case transferred to the Northern District of Texas.

There were no tricks or treats from the federal courts this Halloween week. Instead, most simply shut their blinds, turned off their lights, and pretended not to be home when the children approached their doors hoping for some candy. Full-sized bars were certainly nowhere to be found, but a few courts offered some disappointing bags of raisins. Perhaps the closest thing to a trick was the Fifth Circuit’s panel rehearing of Angelina Emergency Medicine Associates PA v. Blue Cross, which resulted in a ruling that was virtually indistinguishable from the one the court issued in August. Fingers crossed your Halloween haul is more bountiful!

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

Attorneys’ Fees

Sixth Circuit

House-Forshee v. Benefits Comm. of W. & S. Fin. Grp. Co. Flex. Benefits Plan, No. 1:24-cv-110, 2025 WL 2980448 (S.D. Ohio Oct. 23, 2025) (Magistrate Judge Stephanie K. Bowman). Plaintiff Roberta House-Forshee commenced this action against the Benefits Committee of Western & Southern Financial Group Co. Flexible Benefits Plan and Western & Southern Financial Group, Inc. to challenge their denial of her claim for short-term disability benefits under an ERISA-governed policy. After Ms. House-Forshee brought her lawsuit, defendants reversed the denial of her short-term disability benefit claim and subsequently moved to dismiss the case for lack of jurisdiction based on the doctrine of mootness. The court granted the motion to dismiss, but without prejudice to Ms. House-Forshee’s ability to move for a post-judgment award of attorneys’ fees. In response, Ms. House-Forshee filed a fee motion, which defendants opposed. In this decision Magistrate Judge Stephanie K. Bowman recommended the denial of House-Forshee’s motion. As an initial matter, Judge Bowman accepted Ms. House-Forshee’s legal premise that ERISA Section 502(g)(1) can support a discretionary award of fees on the basis of a “catalyst” theory, i.e., that defendants’ voluntary reversal was the result of initiating litigation. However, the court stressed that attorney fee awards under ERISA are discretionary. Furthermore, Judge Bowman was persuaded that in the present matter defendants offered “persuasive evidence that undermines Plaintiff’s position that the settlement email rather than new medical documentation submitted with Plaintiff’s separate LTD claim was the basis for reopening the appeal and awarding STD benefits.” Judge Bowman viewed Ms. House-Forshee’s contrary position as “weak” and “circumstantial.” Thus, “the limited circumstantial proof that Plaintiff has presented in support of a fee award is insufficient, when viewing the record as a whole, to prove that this STD case was a catalyst for the award of STD benefits. And even if a reviewing court were to conclude that Plaintiff’s evidence is sufficient to satisfy Hardt, the undersigned’s evaluation of the King factors also disfavors the award of any fee.” Consequently, Judge Bowman ruled that no attorneys’ fees should be awarded to Ms. House-Forshee.

Ninth Circuit

Nagy v. CEP America, LLC, No. 23-cv-05648-RS, 2025 WL 2960448 (N.D. Cal. Oct. 17, 2025) (Judge Richard Seeborg). Plaintiffs in this class action are employees of the MedAmerica company who sued the fiduciaries of MedAmerica’s 401(k) retirement plan for breach of fiduciary duty under ERISA. Last December the parties reached a settlement, and this May the court granted preliminary approval of the proposed settlement. Following the October 16 fairness hearing, the court issued this decision granting plaintiffs’ motion for an award of attorneys’ fees, reimbursement of expenses, and service awards for the two named plaintiffs. (In a separate motion, plaintiffs moved for final approval of the settlement agreement). In their fee motion plaintiffs requested an award of 25% of the settlement fund, reimbursement for $13,775.84 in litigation expenses, and $10,000 in service awards for each of the two class representatives. To begin, the court found the $2,179,000 in attorneys’ fees reasonable under the Ninth Circuit’s Vizcaino factors, as the overall result and benefit to the class is significant, particularly when considering the risks associated with continued litigation, and because class counsel took the case on a purely contingent basis. Additionally, the court noted that a 25% fee award is consistent with the Ninth Circuit’s characterization of 20-30% as the “usual range” for attorneys’ fee award percentages in common fund cases. And a lodestar cross-check further supported the fee request. The lodestar multiplier in this case was 2.6, which the court stated is less than lodestar multipliers that have been awarded in other ERISA class actions. Moreover, the court agreed with class counsel that they are entitled to reimbursement of $13,775.84 in out-of-pocket costs that were associated with representing the class. These expenses included travel costs, the expense of arbitrators and mediators, legal research fees, and court fees. Finally, the court was comfortable awarding incentive awards of $10,000 to each of the two class representatives in order to compensate them for their years spent collaborating with their attorneys in this lawsuit. For these reasons, the court granted plaintiffs’ motion and the requested awards.

Class Actions

Seventh Circuit

Shaw v. Quad/Graphics Inc., No. 20-cv-1645-pp, 2025 WL 2972286 (E.D. Wis. Oct. 21, 2025) (Judge Pamela Pepper). Five years ago, plaintiff Sharita Shaw filed a class action complaint against the fiduciaries of the Quad/Graphics Diversified Plan, complaining that they had breached their duties to the plan’s participants and beneficiaries in violation of ERISA. In the summer of 2025, the parties finalized a settlement, after eight months of negotiations in private mediation. Ms. Shaw now asks the court to preliminarily approve of the $850,000 settlement. The court granted that request in this order, preliminarily certified the settlement class, and set a fairness hearing for February 18, 2026. To begin, the court agreed with Ms. Shaw that the settlement class meets the requirements of Rule 23(a) and (b)(1). The court determined that the 25,000 member class easily satisfies numerosity, that common questions exist about whether defendants breached their duties to the plan and whether the plan suffered losses as a result, that Ms. Shaw is typical of the other class members who “want to hold the fiduciaries accountable for their alleged breaches,” and that representation by Ms. Shaw and the law firm of Walcheske & Luzi, LLC has been adequate to date. In addition, the court was satisfied that the non-opt out class can be appropriately certified under Rule 23(b)(1) because recovery for the fiduciary breach claims will inure to the plan as a whole and because the fiduciaries need consistent rulings regarding the operation of the plan. As for the settlement itself, the court determined that it appears to be fair, reasonable, and adequate for all the class members, and the result of informed arm’s length negotiations. Further, the court found the $850,000 recovery, which represents 18.9% of the plaintiffs’ estimated losses, decent and in line with other ERISA class action settlements that have received approval from courts across the country. Finally, the court noted that the “risks, costs and potential delay in this case are significant.” Thus, the court granted preliminary approval to the settlement pending the fairness hearing early next year.

Disability Benefit Claims

Ninth Circuit

Lukman v. Metropolitan Life Ins. Co., No. 24-cv-02427-YGR, 2025 WL 2950185 (N.D. Cal. Oct. 9, 2025) (Judge Yvonne Gonzalez Rogers). This litigation stems from plaintiff Vera Lukman’s denied application for long-term disability benefits under a plan insured by defendant Metropolitan Life Insurance Company (“MetLife”). Ms. Lukman submitted a claim for benefits after receiving the maximum duration of short-term disability benefits. She had left work from her position as a software engineer at Google in November 2020 due to a combination of psychiatric and physical symptoms, including concentration issues, cognitive decline, and various somatic impairments, primarily gastrointestinal-related. MetLife offered four reasons for denying Ms. Lukman’s claim: (1) the medical evidence did not demonstrate that she suffered from psychiatric or physical functional limitations, based upon normal physical examinations and labs; (2) Ms. Lukman’s self-reported symptoms were not supported by clinical evidence; (3) her symptoms showed significant improvement over time; and (4) the statements of her physicians and her non-work life activities demonstrated that she could work full-time. In ruling on the parties’ cross-motions for judgment under Federal Rule of Civil Procedure 52, the court considered each of these reasons. Before it did so, however, the court weighed whether to consider Ms. Lukman’s extra-record evidence that she presented to MetLife after it had concluded the appeals process. Ms. Lukman argued that the court should consider this evidence due to MetLife’s failure to comply with ERISA’s regulations governing the notice and disclosure requirements. While it appeared the court found validity in this argument, it nevertheless decided not to consider the extra-record evidence. The court explained that it did not need to rule on this issue because the record evidence provided sufficient information on its own to support a finding in favor of Ms. Lukman under the applicable de novo standard of review. First, the court noted that each of the doctors who examined and treated Ms. Lukman determined that she was unable to perform the duties of her job as a software engineer based on testing, lab work, assessments, their own examinations, and formal diagnoses. It found these factors supported a finding that Ms. Lukman was partially disabled under the plan’s definition of disability. Next, the court rejected MetLife’s argument that Ms. Lukman’s self-reported symptoms failed to demonstrate disability. Not only did none of the treating physicians question the legitimacy of Ms. Lukman’s complaints, but Ms. Lukman “sought treatment for her symptoms as early as 2017 and continued to seek a firm diagnosis and treatment throughout her disability application and appeal, including three-times weekly intensive therapy treatments, sleep tests, and a variety of other examinations. Plaintiff’s treating physicians noted at various times that her physical and psychological symptoms were likely to impact her ability to focus. Moreover, [her doctors] documented [her] inability to concentrate, including that her concentration deteriorated during the relevant time period.” The court added that Ms. Lukman’s inability to concentrate was observed by the treating doctors directly. As a result, the court found that the subjective self-reported symptoms supported a finding of disability. In addition, the court disagreed with MetLife that the record showed improvement in Ms. Lukman’s symptoms or that there was evidence that Ms. Lukman could work full-time. MetLife had argued that Ms. Lukman could work full-time because she attempted to return to work part-time, but the court did not agree. It said instead that Ms. Lukman’s actions were “consistent with an employee who is attempting yet struggling to return to full-time work due to her significant physical symptoms and difficulty concentrating.” Moreover, the court did not find Ms. Lukman’s expressed desire to pursue a PhD at some point as evidence that she was capable of doing so. And the fact that Ms. Lukman’s house was being remodeled was entirely irrelevant in the court’s view, as there was no suggestion that Ms. Lukman was engaging in that work herself. Thus, based on the court’s review of the administrative record, it found that Ms. Lukman established by a preponderance of the evidence that she was partially disabled under the plan’s definition of disability, meaning she was unable to earn 80% or more of her pre-disability earnings. As one final note, the court addressed MetLife’s argument that Ms. Lukman could not meet the plan’s definition of partial disability because she was not working during the claim’s elimination period. The court viewed this argument as “specious” and illogical, and stated that it did not compel a different result. Accordingly, the court entered judgment in favor of Ms. Lukman and ordered the parties to meet and confer to resolve the amount of disability benefits due to her.

ERISA Preemption

Third Circuit

The Plastic Surgery Center, P.A. v. Cigna Health & Life Ins. Co., No. 24-10227 (GC) (JTQ), 2025 WL 2977796 (D.N.J. Oct. 22, 2025) (Judge Georgette Castner). The Plastic Surgery Center, P.A. is a New Jersey-based healthcare provider that specializes in performing plastic and reconstructive surgery. The Plastic Surgery Center filed this lawsuit in state court against Cigna Health and Life Insurance Company alleging claims of breach of contract, promissory estoppel, and negligent misrepresentation after Cigna covered only a fraction of billed costs for a medically necessary surgical procedure it performed on an insured patient. Plaintiff maintains that Cigna’s rate of reimbursement was contrary to the terms of the single case agreement the parties entered into before the surgery, wherein Cigna agreed to compensate the surgery center at in-network rates. After removing the lawsuit to federal court based on diversity jurisdiction, Cigna filed a motion to dismiss the complaint pursuant to Federal Rule of Civil Procedure12(b)(6). Cigna advanced two arguments: (1) ERISA Section 514 preempts the state law causes of action; and (2) assuming ERISA is not found to preempt plaintiff’s claims, plaintiff failed to plausibly plead each of its three causes of actions. The court addressed each argument and explained why it disagreed with them both. Concerning ERISA preemption, the court determined that the claims neither make reference to the patient’s plan nor have an impermissible connection to it. Specifically, the court determined that the single case rate agreement is a separate obligation for which Cigna incurred an independent contractual duty, which expressly disclaims any relationship to the ERISA-governed plan. Further, the court stated that the “alleged agreement at the heart of Plaintiff’s claims mentions the Plan only for its in-network payment rates,” and “[i]dentifying these in-network rates requires only ‘cursory examination’ of the in-network provider fee schedule.” The court also concluded that the alleged agreement does not affect the relationship among traditional ERISA entities, and that the claims won’t interfere with plan administration, or undercut ERISA’s stated purpose of protecting plan participants and beneficiaries. For these reasons, the court disagreed with Cigna that the state law causes of action are expressly preempted. The court then addressed the sufficiency of the state law claims as pled, and concluded that at this stage of the proceedings, the complaint’s allegations sustain all three claims. Accordingly, the court denied Cigna’s motion to dismiss in its entirety.

Exhaustion of Administrative Remedies

Second Circuit

Lucas v. Hartford Life & Accident Ins. Co., No. 24-CV-7561 (VEC), 2025 WL 2961561 (S.D.N.Y. Oct. 20, 2025) (Judge Valerie E. Caproni). Plaintiff Suzanne Lucas brings this ERISA case to challenge defendant Hartford Life and Accident Insurance Company’s decision to terminate her long-term disability benefits. Before the court were motions filed by Hartford for a stay of the case and remand for further consideration of the claim, or alternatively, for leave to file a motion for summary judgment on the issue of administrative exhaustion. Ms. Lucas opposed Hartford’s motions. She argued that Hartford failed to decide her appeal within 45 days and that it had therefore forfeited any opportunity for further administrative review. In this decision the court decided not to remand to Hartford at this juncture, but to allow it to file a motion for summary judgment on the ground that Ms. Lucas failed to exhaust her administrative remedies. The court declined to remand Ms. Lucas’s claim to Hartford because it stated that remand is a remedy to be imposed after a review of an ERISA benefits determination. Because the court has yet to conduct any review in this case, it concluded that it would be premature to remand to Hartford at this point in the litigation. However, the court disagreed with Ms. Lucas’s assertion that Hartford’s failure to comply with ERISA’s 45-day decision window forecloses its ability to order remand at any point. On the contrary, the court said her argument about Hartford’s non-response to her appeal is better suited in response to the question of whether her duty to exhaust has ceased, and stated that she was conflating administrative exhaustion with remand. While the court pointedly expressed no view as to whether Ms. Lucas has satisfied her duty to exhaust, it nevertheless determined that Hartford should be permitted to raise that threshold issue. Therefore, the court found it appropriate to grant Hartford leave to move for summary judgment on this basis. Accordingly, to the extent Hartford’s motion requested this relief, it was granted.

Life Insurance & AD&D Benefit Claims

Fourth Circuit

Estate of Green v. The Hartford Life & Accident Ins. Co., No. 24-cv-1910-ABA, 2025 WL 2986815 (D. Md. Oct. 23, 2025) (Judge Adam B. Abelson). On June 1, 2019, Sidney Green died in a motorcycle accident. The week before his death, Mr. Green had been let go from his work at Piedmont Airlines, Inc. Due to this termination, The Hartford Life and Accident Insurance Company denied Mr. Green’s family’s claim for accidental death benefits. Mr. Green’s Estate brought this case to challenge that denial. Both parties moved for judgment in their favor. In this decision the court concluded that Hartford’s denial was not an abuse of discretion, and thus granted judgment in its favor. In particular, the court emphasized that the plan terms make clear that coverage ends on “the date Your Employer terminates Your employment.” Thus, the court found that the denial was appropriate, as there was no genuine dispute that as of the date of his death Mr. Green was no longer an active employee of Piedmont and thus no longer a participant in the accidental death plan. The court therefore agreed with Hartford that the record evidence supported its conclusion that Piedmont had terminated Mr. Green’s employment prior to his death and that his family was not eligible for the benefits. Aside from this holding, however, the court also agreed with Hartford that Mr. Green’s family failed to timely exhaust the internal appeals procedures as required by the plan. The court concluded that there was no genuine dispute that the family’s appeal letter “was untimely under both the unambiguous language of the Plan and the calculation of the 180-day deadline in the denial letter.” Accordingly, the court held that the Estate failed to timely exhaust the internal appeals procedures and that Hartford was also entitled to summary judgment on this basis. For these reasons, the court granted Hartford’s motion for summary judgment and denied the Estate’s cross-motion.

Fifth Circuit

Metropolitan Life Ins. Co. v. Wallace, No. 3:24-CV-1520-X, 2025 WL 2986137 (N.D. Tex. Oct. 22, 2025) (Judge Brantley Starr). Facing competing claims to benefits under employer-sponsored life insurance coverage and accidental death coverage belonging to decedent Ambrose Bless, Metropolitan Life Insurance Company (“MetLife”) filed this interpleader action. In an earlier decision the court granted MetLife’s motion for interpleader relief. Here, the court ruled on defendant Jennifer Leigh Wallace’s motion for summary judgment. Under the terms of the plans MetLife had the discretion to decide who should receive the benefits in the event there was no designated beneficiary. Moreover, the policies stated that the payments should be made to the decedent’s spouse or domestic partner before the decedent’s parents. Mr. Bless and Ms. Wallace were common-law spouses, together for decades. The two owned a house and shared a bank account. Referring to this information, MetLife concluded that Ms. Wallace was a higher-priority beneficiary than Mr. Bless’s parents. When the parents challenged this decision, MetLife requested that the court step in. In this decision the court concluded, “MetLife’s denial of the Bless Parents’s claims – based on its determination that Jennifer Leigh Wallace qualified as Mr. Bless’s Domestic Partner under the Plans – is uncontroverted, supported by the evidence, and therefore the Benefits under the Plans should be awarded to Wallace.” Consequently, the court granted Ms. Wallace’s motion for judgment.

Pleading Issues & Procedure

Fourth Circuit

Rose v. Guardian Life Ins. Co. of Am., No. 8:25-cv-03866-DCC, 2025 WL 2972236 (D.S.C. Oct. 21, 2025) (Judge Donald C. Coggins, Jr.). Plaintiff David Rose filed this action against Guardian Life Insurance Company of America bringing claims for breach of contract, bad faith, improper claim practices, and violations of ERISA in connection with numerous payment issues concerning his long-term disability benefits. Guardian moved to dismiss Mr. Rose’s action, and also moved to strike his jury trial request. The court granted in part and denied in part the motion to dismiss, and granted the motion to strike. As an initial matter, the court dismissed the state law claims, as Mr. Rose consented to their dismissal. The court then turned to the question of whether Mr. Rose’s ERISA claims are barred by the relevant statute of limitations. Mr. Rose asserted various ERISA claims, including claims for statutory penalties, fiduciary breach, and benefits. ERISA provides the statute of limitations for the fiduciary breach claims, while the policy sets forth a three-year limitations period for the plan-based claims. At this juncture, the court could not say whether any of the ERISA claims are barred by any applicable statute of limitations, and because it is unclear from the record currently before the court whether the statutes of limitations are applicable to this action, the court declined to dismiss any of the claims as untimely at this early stage in the proceedings. However, the court granted the motion to dismiss the claim for statutory penalties, as it is undisputed that the plan administrator of the long-term disability policy is Barnes Group, Inc., not Guardian, and the penalties provided for in ERISA § 502 apply only to plan administrators. Finally, the court granted the motion to strike the jury demand “because ERISA provides essentially equitable relief for which jury trials typically do not lie.”

Sixth Circuit

Chaudron v. Edward Jones & Co., No. 2:25-CV-73, 2025 WL 2979695 (E.D. Tenn. Oct. 22, 2025) (Magistrate Judge Cynthia R. Wyrick). In this action plaintiff Kaylin G. Chaudron challenges defendants Edward Jones & Co. L.P. and Metropolitan Life Insurance Company’s denial of claims for life insurance and short-term disability benefits. Before the court was Ms. Chaudron’s motion to amend her complaint to add a claim for breach of fiduciary duty pursuant to Section 502(a)(3), to add a claim for civil penalties based on Edward Jones’s failure to provide her with a complete file, and to seek relief and damages against the defendants “under state and federal law…to the extent deemed applicable and appropriate.” Defendants opposed Ms. Chaudron’s request for leave to amend, and argued that the proposed amendments are futile. Agreeing, the court denied Ms. Chaudron’s motion. First, the court concurred with defendants that the breach of fiduciary duty claim does not seek appropriate equitable relief, and is instead duplicative of her claims for benefits under Section 502(a)(1)(B) because it is based on the same facts and injuries. Second, the court agreed with defendants that Ms. Chaudron cannot maintain a statutory penalty claim because under Sixth Circuit case law such claims only apply for failure to provide specific documents expressly enumerated under § 1024(b)(4). It held, “Plaintiff has not clearly stated what documents she requested from Defendants that were not provided, making it impossible for the Court to determine whether Plaintiff has set forth a plausible claim for civil penalties pursuant to § 1132(c).” Finally, the court took issue with the inclusion of the generic request for relief and damages under undefined state and federal law. Regarding state law, the court found the amendment futile because ERISA governs this action and would preempt any state law claims. And as for federal law, the court found that Ms. Chaudron already includes a general reservation of rights provision in her original complaint, which renders the inclusion of a new general reservation of rights clause unnecessary. Based on the foregoing, the court found the proposed amendments futile at this juncture, and thus denied plaintiff’s motion for leave to include them.

Nirenberg v. Couzens, Lansky, Fealk, Roeder & Lazar, P.C., No. 24-cv-10619, 2025 WL 2976842 (E.D. Mich. Oct. 17, 2025) (Judge Robert J. White). Plaintiff Henry Nirenberg is a state court-appointed fiduciary who filed this case in state court asserting claims for (1) legal malpractice against Defendants Jack S. Couzens and the law firm Couzens, Lansky, Fealk, Roeder & Lazar, P.C. (the Couzens Defendants); (2) legal malpractice against Defendants Mark W. Sadecki and the law firm Sadecki & Associates, P.L.L.C. (the Sadecki Defendants); (3) breach of trust and an ERISA violation against Defendants Kathleen Jenkins and the accounting firm Jenkins, Magnus, Volk, and Carrol, P.C. (the Jenkins Defendants); (4) conversion against the Couzens Defendants, Jenkins, and Defendant Susan Habel; and (5) an ERISA claim against Ms. Habel. All of these claims arise from allegedly improper distributions from two trust accounts, the Harold B. Doremus Trust (the HBD trust) and the Burke Building Centers Inc. Profit Sharing Trust (the PSP trust). The PSP trust is governed by ERISA. Several motions were before the court. Mr. Nirenberg moved to remand his state law causes of action back to state court. Ms. Habel, the Couzens Defendants, and the Sadecki Defendants all filed respective motions to dismiss Mr. Nirenberg’s claims. Finally, the Couzens and Sadecki Defendants filed motions to dismiss the Jenkins Defendants’ crossclaims. The court denied the motion to remand, granted Ms. Habel’s motion to dismiss, granted in part and denied in part the Legal Defendants’ motions to dismiss the crossclaims, denied the Sadecki Defendants’ motion to dismiss Mr. Nirenberg’s claims, and granted in part and denied in part the Couzens Defendants’ motion to dismiss Mr. Nirenberg’s claims. To begin, the court denied Mr. Nirenberg’s motion seeking to remand the state claims back to state court because it concluded that the state and federal claims arise from a common nucleus of operative facts and are inextricably intertwined with one another. As a result, the court concluded that supplemental jurisdiction over the state law claims is warranted. Regarding the ERISA claim asserted against Ms. Habel, the court held that it must be dismissed because the HBD trust, as the beneficiary of the deprived funds, failed to exhaust administrative remedies. Although Mr. Nirenberg styled his ERISA claim against Ms. Habel as a statutory breach of fiduciary duty claim, the court nevertheless felt that it was essentially a claim alleging improper distributions contrary to the terms of the PSP trust and therefore fundamentally a plan-based claim subject to the exhaustion requirement. Moreover, the court also concluded that Mr. Nirenberg failed to sufficiently plead that Ms. Habel knew, when she became the PSP trustee, that the distributions were improper. However, the court allowed the ERISA claim against the Jenkins Defendants to proceed, as well as the legal malpractice claims, the breach of trust claim, and some of the Jenkins Defendants’ crossclaims. The remaining state law claims and crossclaims were all dismissed for various non-ERISA-related reasons. Accordingly, the court’s ruling was mixed for almost all of the parties, and resolution of large parts of this action will not take place until after discovery has concluded.

Provider Claims

Fifth Circuit

Angelina Emergency Medicine Associates PA v. Blue Cross & Blue Shield of Alabama, No. 24-10306, __ F. 4th __, 2025 WL 2984898 (5th Cir. Oct. 23, 2025) (Before Circuit Judges Smith, Higginson, and Douglas). Plaintiffs-appellants in this ERISA action are fifty-six Texas emergency medicine physician groups who sued twenty-four Blue Cross Blue Shield-affiliated plans from outside of Texas alleging that the Blue Plans underpaid them for 290,000 reimbursement claims. After a settlement with some of the defendants, more than 75% of the claims were dismissed. The district court later granted summary judgment in favor of defendants on the remaining claims. The district court identified five issues with plaintiffs’ claims: (1) the physician groups were not named in the assignments; (2) the assignments did not include a right to sue; (3) the assignments themselves were not produced; (4) the underlying plans contained valid anti-assignment clauses; and (5) the physician groups failed to exhaust administrative remedies under the applicable plans before filing suit. (Your ERISA Watch reported on this ruling in our January 17, 2024 edition.) Plaintiffs appealed. On August 8, 2025, the Fifth Circuit revived nearly all of plaintiffs’ claims, affirming the district court’s decision only as to the claims where no written assignment was produced. In that decision, the court of appeals identified several issues that require further examination. First, the Fifth Circuit held that the lower court was wrong to dismiss the provider’s claims for lack of standing because the assignments were made to “health care providers” rather than naming the physician groups themselves. The court of appeals agreed with plaintiffs that the term “provider” is ambiguous and subject to two or more reasonable interpretations. At a minimum, the Fifth Circuit held that the lower court should have allowed the parties to introduce evidence of the intended scope of the assignments, and its grant of summary judgment was accordingly premature. Next, the Fifth Circuit rejected the district court’s holding that the assignments provided only a right to administrative relief rather than the right to seek legal relief. The appeals court stressed that the assignments assign “all rights.” It wrote, “there is no basis in the law for requiring that an assignment specifically state it provides a right to sue when it assigns ‘all rights.’ The district court erred in finding that claims assigning rights or insurance benefits did not assign a right to sue.” The Fifth Circuit then turned to the claims where the physician groups do not have written assignments. The court of appeals affirmed the dismissal of these claims and concluded that the district court acted reasonably in doing so. In addition to finding issues with the assignments, the district court had also dismissed claims where the underlying plans contained anti-assignment provisions. The Fifth Circuit reversed this basis for dismissal. It concluded that there were genuine issues and open questions about whether the Blue Plans were estopped from enforcing the anti-assignment clauses. It stated that the matter of estoppel “is a fact issue that the district court must determine as to each claim.” Finally, the Fifth Circuit held that the district court was too quick to dismiss claims for failure to exhaust administrative remedies. “At bottom, the Physician Groups argue that they made all possible efforts to obtain the underlying plans and understand alternative appeals processes, while still following the publicly available appeals process, but were not given copies of the plan. We have previously held that a claimant’s efforts, or lack thereof, to obtain the plan can be a key fact in finding whether the claimant has cleared the hurdle of ERISA exhaustion. At a minimum, there is a factual dispute as to whether the Physician Groups could have discovered the member appeals process without action by [Blue Cross], and whether it would have been reasonable to require the Physician Groups to undertake that separate process when they were already being partially paid by [the Blue Plans].” Based on the foregoing, the Fifth Circuit vacated summary judgment as to all claims except those with no written assignment in evidence. Blue Cross then petitioned for rehearing en banc. Treating Blue Cross’s motion as a petition for panel rehearing, the Fifth Circuit granted the motion, withdrew its previous opinion, and substituted it with a new one this week. The new decision is very similar to the previous one. On the whole, the Fifth Circuit maintained its prior holdings, and in the end reached the same result – affirming summary judgment as to the claims with no written assignment in evidence and otherwise vacating summary judgment as to the remaining claims. Accordingly, the appeals court once again remanded these remaining claims to the district court for evidentiary determinations as to the validity of the underlying assignments and the exceptions to exhaustion. Thus, despite granting Blue Cross’s motion, the panel upheld its previous positions, and things stand today where they stood a few months ago, with the physician groups’ action resurrected, and with the possibility that plaintiffs may yet receive further compensation for some or all of the remaining claims at issue.

Bolton v. Inland Fresh Seafood Corp. of Am., Inc., No. 24-10084, __ F.4th __, 2025 WL 2924493 (11th Cir. Oct. 15, 2025) (Before Circuit Judges Jordan and Jill Pryor, and District Judge Federico A. Moreno)

If you want to sue an employee benefit plan because it has denied your claim, federal courts typically require you to first “exhaust your remedies,” i.e., complete all the appeal steps in your plan’s internal review procedure.

However, many benefit-seekers are surprised to learn that this bedrock rule is nowhere to be found in ERISA, the statutory scheme that governs employee benefits. Instead, it is purely an invention by the courts. The courts have provided various public policy reasons for adopting this rule, including (a) ERISA’s similarity to the Labor Management Relations Act, which requires exhaustion, (b) ERISA’s requirement that plans adopt internal review procedures, which plans and participants should be encouraged to use, (c) minimizing the costs of claim settlement, and (d) allowing the facts and issues to be fully fleshed out prior to litigation, among others.

However, plan participants have several remedies under ERISA. They are not simply limited to suing for benefits; they can sue for violations of the statute itself. Do those claims require exhaustion as well? It is this issue that the Eleventh Circuit addressed in our case of the week.

The plaintiffs are participants in the pension plan of Inland Fresh Seafood Corporation of America, Inc., which is an employee stock ownership plan. The plan was created in 2016 when the company used a $92 million loan to purchase all outstanding shares of the company’s stock from the company’s directors and officers.

The plaintiffs criticized this transaction, contending that various defendants breached their fiduciary duties under ERISA Sections 502(a)(2) and (a)(3). The plaintiffs contend that the defendants caused the plan to overpay for the stock by tens of millions of dollars, simultaneously enriching the defendants while devaluing the plaintiffs’ benefits. The plaintiffs sought equitable relief, including “restoration of the plan’s losses, disgorgement of the director and officers’ ill-gotten gains, and other forms of equitable relief.”

There was no dispute that the plan contained an internal appeals procedure. However, the plaintiffs did not exhaust their remedies under that procedure and instead went directly to federal court. In court, plaintiffs contended that (a) they had no obligation to exhaust the plan’s internal appeals, and (b) assuming such an obligation existed, they should be excused from that requirement.

The district court ruled that exhaustion was required and that the plaintiffs were not excused. The district court also refused to grant the plaintiffs a stay so they could pursue a claim under the plan’s procedure, and dismissed the case.

The plaintiffs appealed. The Eleventh Circuit began by acknowledging that while “[a]ll circuits require exhaustion in the ERISA context,” the Eleventh Circuit was special. “Where we diverge is in our application of the exhaustion requirement to statutory violation claims.” The court created this rule 40 years ago in Mason v. Continental Group, 763 F.2d 1219 (11th Cir. 1985). This requirement “is at odds with a large chorus of our sister circuits which – though they require exhaustion for benefits claims – do not require exhaustion for claims alleging violations of ERISA.”

The plaintiffs were well aware of this precedent, but contended that now was the time for the Eleventh Circuit to change its ways and join its fellow courts. However, the court stated, “We reject that call now, just as we have done before… Whatever we may feel about our exhaustion precedent does not relieve us of our responsibility to apply it. After all, a prior published panel decision ‘is controlling ‘unless and until it is overruled or undermined to the point of abrogation by the Supreme Court or by this court sitting en banc.’’”

Plaintiffs contended that the Eleventh Circuit’s rule had been undermined by intervening Supreme Court precedent. However, the court noted that this argument faced “a demanding standard.” To prevail, plaintiffs were required to present a Supreme Court decision that was “clearly on point and clearly contrary to the panel precedent.” In short, it “‘must demolish and eviscerate each of [the] fundamental props’ of the prior-panel precedent.” The Eleventh Circuit determined that none of plaintiffs’ cases were on point – their primary case involved the Prison Litigation Reform Act (“PLRA”), not ERISA – and did not “demolish” or “eviscerate” Mason.

Next, the court addressed plaintiffs’ argument that they were not required to plead exhaustion. Plaintiffs contended that exhaustion is an affirmative defense that defendants must prove, and thus the burden should not fall on plaintiffs to plead compliance. The Eleventh Circuit did not directly resolve the issue of pleading requirements. Instead, it ruled that through their pleading, amendments, and arguments to the district court it was clear that the plaintiffs had “effectively conceded that they did not exhaust before filing suit. It would thus serve no purpose to remand for the district court to entertain a possible amendment from the plaintiffs or for further factual development on exhaustion.” As a result, “We cannot say the district court abused its discretion in dismissing the amended complaint on account of the plaintiffs’ failure to plead exhaustion or a valid exception.”

The plaintiffs also argued on appeal that even if exhaustion was required, that requirement should be excused because (1) the committee to which the plaintiffs would be required to appeal “cannot address the plaintiffs’ claims or provide the relief they seek,” (2) the plan language did not require exhaustion, and (3) exhaustion would have been futile.

The Eleventh Circuit rejected all three arguments. On the first argument, plaintiffs contended that the committee was “limited to administrative tasks or to correcting mistakes of fact in calculating benefits due under the plan, rather than addressing breaches of fiduciary duty,” and that it was not empowered to “hold the defendants personally liable for causing millions of dollars in losses to the plan and compel them to make the plan whole.” The court, however, did “not read the plan or the claims procedures as narrowly as the plaintiffs do.” The court found that the committee had the power “to take up the plaintiffs’ claims” and that the plan “at least ‘offers the potential for an adequate legal remedy.’”

As for plaintiffs’ second argument, the Eleventh Circuit disagreed that “the plan’s language makes exhaustion optional.” The plaintiffs focused on the plan’s permissive language, which provided that participants “may” submit claims, “may” seek review, and “may” file a lawsuit. However, the court concluded that this language “merely reminds the plaintiffs of their ‘general rights under ERISA’ to eventually seek judicial review, but it does not affirmatively excuse them from exhausting the plan’s required claims procedures.” In any event, the court ruled that the plan’s arbitration clause “dispenses with any lingering ambiguity” because it requires participants to bring claims in arbitration, including “claims for breach of fiduciary duty,” and before doing so, “the plan’s claims procedures…must be exhausted.”

The Eleventh Circuit ruled against plaintiffs on their futility argument as well. Plaintiffs contended that it would have been pointless to engage in the plan’s internal review procedure because the outcome was foreordained. However, the court agreed with the district court that the plaintiffs had not presented sufficient evidence to prove that an appeal would have been pro forma. The court acknowledged plaintiffs’ allegations regarding defendants’ conflicts of interest and their adversarial approach to document production, but ultimately ruled that these facts should not “invalidate an administrative proceeding before it has even begun… In fact, the plaintiffs’ futility arguments are premature and speculative because they did not even attempt to exhaust before filing suit. This alone justifies disregarding those arguments.”

Next, the Eleventh Circuit ruled that the district court properly denied plaintiffs’ request for a stay to allow them to exhaust their claims with the plan. The court criticized plaintiffs on procedural grounds, noting that they had not filed a formal motion for such relief, and also questioned their substantive argument that without a stay, their claims might run afoul of the statute of limitations. The court noted that plaintiffs’ claims might not in fact be time-barred because ERISA’s “fraud or concealment” provision might apply to extend their time limit. Plaintiffs complained that they should not have to prove this, but the court ruled that this was the cost of refusing to engage in the plan’s appeal process.

At this point in the opinion the outlook for plaintiffs was obviously bleak. However, things turned quickly. First, the Eleventh Circuit agreed with plaintiffs that the case should be remanded for the district court to specify “the prejudicial scope of its order.” Although the district court had dismissed the action, it did not state whether its dismissal was with or without prejudice. The Eleventh Circuit thus ordered the case to be sent back for clarification.

Even more important was the concurrence by Judge Jordan, which was joined by Judge Pryor. (The panel decision was written by district judge Federico A. Moreno of the Southern District of Florida, sitting by designation.) Judge Jordan complimented Judge Moreno for his “well-written opinion” which he “join[ed]…in full.” However, Judge Jordan stated that he was writing separately “to propose that we convene en banc to consider overruling Mason[.]” Judge Jordan criticized Mason because it “imposed a judicially-created and atextual administrative exhaustion requirement for fiduciary-breach and statutory claims under ERISA,” and offered five “good reasons” for overruling it.

First, Judge Jordan noted that ERISA was a “comprehensive and reticulated” act which does not mention exhaustion at all. “We should not impose a requirement that Congress has omitted.”

Second, Mason created the exhaustion requirement for policy reasons. However, in the PLRA context, as plaintiffs argued, the Supreme Court “has told the lower federal courts that ‘crafting and imposing’ exhaustion rules that ‘are not required’ by the text of a federal statute ‘exceeds the proper limits on the judicial role.’” As a result, “Mason erred in relying on policy considerations to create an atextual exhaustion requirement for fiduciary-breach and statutory claims under ERISA.” If ERISA is to have an exhaustion requirement, “that is a result which must be obtained by the process of amending [ERISA], and not by judicial interpretation.”

Third, Judge Jordan noted that the Eleventh Circuit was out of step with seven other circuits on this issue. Only one other circuit – the Seventh – agreed with the Eleventh, but Judge Jordan noted that the statutory provision on which the Seventh Circuit relied “‘refers only to procedures regarding claims for benefits,’ and therefore does not support creating an exhaustion requirement for non-benefit claims.” Furthermore, the Seventh Circuit’s requirement is less onerous than the Eleventh’s; it is discretionary, not mandatory.

Fourth, Judge Jordan cited secondary authorities, which supported the majority position that exhaustion should not be required in statutory violation actions, and fifth, he observed that “the issue is an important one that is likely to recur.” Judge Jordan noted (and regular readers of Your ERISA Watch are well aware) that fiduciary breach actions are on the rise. Thus, he concluded, “I urge my colleagues to vote to rehear this case en banc and consider overruling Mason.”

As a result, while the outcome was a clear loss for the plaintiffs, they are surely hoping that this was merely a skirmish in the larger war that will play out in front of an en banc Eleventh Circuit. Will the full court reconsider and overrule their 40-year-old exhaustion requirement for statutory ERISA claims? Stay tuned!

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

Attorneys’ Fees

Ninth Circuit

Oksana B. v. Premera Blue Cross, No. C22-1517 MJP, 2025 WL 2931170 (W.D. Wash. Oct. 15, 2025) (Judge Marsha J. Pechman). Plaintiffs in this action are a family that sued Premera Blue Cross, The Tableau Software, Inc. Employee Benefit Plan, and Salesforce.com Health and Welfare Plan under ERISA after their claims for the son’s stay at two residential mental health care facilities, Second Nature and Catalyst, were denied. The district court granted summary judgment in the family’s favor, finding that Premera had abused its discretion and wrongly denied plan benefits for both facilities. The court then issued a decision finding that plaintiffs achieved a high degree of success and awarded the family $49,552.50 in attorneys’ fees and $400 in costs under Section 502(g)(1). Defendants appealed these decisions to the Ninth Circuit. The appeals court reversed the grant of summary judgment in part, holding that the plan did not cover the stay at Second Nature. However, the Ninth Circuit agreed with the district court’s analysis and conclusion that defendants violated ERISA in denying the Catalyst claim and that plaintiffs made a strong showing that they were entitled to coverage. Nevertheless, the Ninth Circuit found that remand to Premera was the appropriate remedy, not an outright award of benefits. Additionally, the court of appeals vacated the award of fees so the lower court could “conduct that analysis anew” in light of its decision. In response, plaintiffs filed a renewed motion for attorneys’ fees, asking for an award of $41,827.50 in fees, and $400 in costs, reducing their fee request by $7,725 to reflect the exclusion of time entries that counsel identified as being solely related to the Second Nature claim. Defendants argued that plaintiffs should not be awarded any attorneys’ fees or costs because they only obtained remand of their Catalyst-related claim to Premera, and otherwise lost their claim concerning the Second Nature stay. The court did not agree. It found that plaintiffs remained entitled to fees under ERISA even after the Ninth Circuit’s decision. “Although Plaintiffs lost their claim that Premera wrongly denied coverage for the Second Nature stay, Plaintiffs succeeded before both this Court and the Ninth Circuit in demonstrating that Premera abused its discretion in denying the Catalyst claim. And both courts have agreed that Plaintiffs made a strong showing that they are entitled to coverage. Thus, the remand is not merely a ‘purely procedural victory’ that falls short of satisfying § 1132(g)(1). Instead, Plaintiffs succeeded in obtaining a meaningful opportunity to obtain benefits. This supports an award.” Moreover, consistent with its previous order, the court found that the Ninth Circuit’s Hummell factors all supported an award of fees and that an award here was appropriate. However, the court agreed with defendants that a haircut over and above plaintiffs’ proposed $7,725 was proper to reflect the mixed success. Ultimately, the court settled on a 20% reduction to the total time billed. The result was an attorneys’ fee award of $39,642, which is 80% of $49,552.50 it originally ordered. Finally, the court again awarded $400 in costs for the filing fee.

Breach of Fiduciary Duty

Fifth Circuit

Lee v. R&R Home Care, Inc., No. 24-836, 2025 WL 2938696 (E.D. La. Oct. 16, 2025) (Judge Susie Morgan). Plaintiffs Douglas Lee, II and Ashlynn Estay bring this action as the beneficiaries of decedent Karen Lee. Before her death, Ms. Lee was an employee of Medical Brokers Management, Inc. and R&R Home Care, Inc. Through her employment, Ms. Lee was a participant in a life insurance benefit plan insured by United of Omaha Life Insurance Company; Mr. Lee and Ms. Estay were the intended beneficiaries. However, unbeknownst to Ms. Lee, on March 1, 2022, the group insurance policy was terminated by United of Omaha. The owner of Medical Brokers Management, Jay Weil, III, allegedly received notice of this termination, but failed to notify Ms. Lee that the policy had terminated or that she had the option to port her coverage to an individual policy, even though United of Omaha had provided Mr. Weil with a sample letter to send to employees to notify them of the termination and to explain options for portability. Moreover, despite the coverage termination, the employers continued to deduct life insurance premiums from Ms. Lee’s paycheck. And, because they failed to notify Ms. Lee when the life insurance policy was cancelled, she was deprived of the opportunity to make other arrangements to obtain life insurance coverage for her heirs. Plaintiffs also allege that defendants failed to provide Ms. Lee with an accurate summary plan description as required by ERISA. Finally, plaintiffs maintain that defendants failed to attempt to obtain new life insurance coverage for Ms. Lee after the United of Omaha policy was terminated. In their lawsuit filed last April, plaintiffs assert that Medical Brokers Management, R&R Home Care, and Mr. Weil committed fiduciary breaches under ERISA and violated Louisiana state law through their actions. Defendants moved to dismiss the complaint. In this decision the court granted in part and denied in part the motion to dismiss. To begin, the court allowed the ERISA fiduciary breach claims to proceed against all three defendants, except to the extent that they alleged defendants breached a duty by failing to obtain new life insurance coverage post-termination. The court stressed that because employers do not have a duty under ERISA to create a plan, and because fiduciary duties exist only while a plan is in effect, the defendants could not have been acting in a fiduciary capacity by failing to secure other life insurance coverage for the employees. Accordingly, the court concluded that plaintiffs failed to state a cognizable ERISA claim based on this conduct. Even so, the court otherwise found that plaintiffs plausibly alleged in all other respects that defendants were acting as fiduciaries, that they breached duties owed to Ms. Lee, and that Ms. Lee was harmed because of the alleged breaches. Moreover, the court concluded that plaintiffs seek the appropriate equitable remedies of surcharge and accounting based on the alleged breaches. The court also found that plaintiffs sufficiently alleged ERISA estoppel claims against all three defendants and denied the motion to dismiss as to these claims. Finally, the court considered plaintiffs’ claims under Louisiana law for breach of fiduciary duty, breach of contract, and detrimental reliance. It quite easily determined that these causes of action were completely preempted by ERISA and that they must be dismissed on that basis. Nevertheless, the court dismissed the claims without prejudice and granted plaintiffs leave to amend their complaint to replead these claims as causes of action under ERISA should they wish to. Thus, as explained above, the court granted in part and denied in part the motion to dismiss.

Class Actions

Ninth Circuit

Chea v. Lite Star ESOP Committee, No. 1:23-cv-00647-SAB, 2025 WL 2938836 (E.D. Cal. Oct. 16, 2025) (Magistrate Judge Stanley A. Boone). Plaintiff Linna Chea filed a motion for preliminary approval of class action settlement and class certification in this ERISA action challenging a 2017 stock transaction involving the Lite Star Employee Stock Ownership Plan. The court granted Ms. Chea’s motion in this order. To begin, the court found that for settlement purposes the class of plan participants and beneficiaries meets the requirements of Rule 23(a) and that certification is appropriate under either subsection Rule 23(b)(1)(a) and 23(b)(1)(B). With regard to Rule 23(a), the court determined that the 200-member settlement class is sufficiently numerous, that the class is united through common questions of law and fact surrounding the transaction, that the alleged harm and underlying conduct are not unique to Ms. Chea but are shared across the class, and that Ms. Chea and her counsel will adequately and fairly protect the interests of the class. As for Rule 23(b), the court found certification appropriate under both Rule 23(b)(1)(A) and 23(b)(1)(B) as resolving the fiduciary breach and prohibited transaction claims on an individual basis runs the risk of creating conflicting judgments, and because the decisions regarding the allegations regarding the transaction will apply to the plan as a whole and affect the rights and interests of all of the participants. Based on the foregoing, the court found that the class should be certified for settlement purposes. It then discussed the particulars of the settlement itself. The settlement agreement provides $2.25 million in aggregate economic value to the plan and its participants. This gross settlement amount represents approximately 45% of the estimated maximum damages. The court concluded that the total relief is within the range of reasonableness, especially when factoring in the considerable risk and time associated with continued litigation. Not only was the court confident for preliminary purposes that the settlement is fair, reasonable, and adequate, but it also concluded that it was the product of an informed arm’s length negotiation, and that it will treat the members of the class equitably. Moreover, the court approved the plan of allocation, and the plan and content of the proposed notice. As for attorneys’ fees, the court concluded that the intended amount of fees, $500,000 (or 22% of the settlement fund), did not present a barrier to preliminary approval of the settlement. For these reasons, the court granted the motion for preliminary approval of the proposed settlement, and scheduled a final approval hearing to be held on January 21, 2026.

ERISA Preemption

Third Circuit

The Plastic Surgery Center, P.A. v. United Healthcare Ins. Co., No. No. 24-10856 (MAS) (TJB), 2025 WL 2918662 (D.N.J. Oct. 14, 2025) (Judge Michael A. Shipp). In last week’s newsletter, Your ERISA Watch reported on two decisions ruling on motions to dismiss in lawsuits brought by The Plastic Surgery Center, P.A. against United Healthcare Insurance Company seeking the outstanding balances of medical bills for care it provided to patients insured under healthcare plans administered by United. This week, the court issued a third nearly identical decision in yet another such lawsuit. As in its related actions, The Plastic Surgery Center asserts three counts against United for breach of contract, promissory estoppel, and negligent misrepresentation, and as before, United moved to dismiss all three. United argued that the factual allegations supporting the purported contracts are refuted by the transcripts of the calls at issue and by the other correspondence between the parties, that the state law claims are expressly preempted by ERISA, and that the complaints fail to state claims upon which relief can be granted. The court disagreed with United that the factual allegations in the complaints are refuted by the pre-authorization communications, and that ERISA preempts the state law claims. Specifically regarding preemption, the court found that the claims asserted do not reference the ERISA-governed healthcare plan and are not impermissibly connected to it. Rather, it determined that these claims arise from independent agreements for coverage based on promises stemming outside of the plans, meaning they will not require interpretation of the plans in order to be resolved. Thus, the court agreed with the provider that the existence of a plan is not a critical factor in establishing liability for the claims here. Accordingly, the court held that plaintiff’s state law claims are predicated on an independent contractual or quasi-contractual duty and that Section 514 does not preempt them. After making these initial holdings, the decision turned to the sufficiency of the three state law claims. The court concluded that plaintiff adequately alleged each of the elements of its breach of contract and promissory estoppel claims under New Jersey law, but that it failed to state a viable claim for negligent misrepresentation. Instead, it found that the negligent misrepresentation claim was barred by the economic loss doctrine because the allegations surrounding this claim stem directly from United’s performance under the contracts. Accordingly, the court granted United’s motion to dismiss the negligent misrepresentation claim, but denied the motion as to the breach of contract and promissory estoppel claims.

Seventh Circuit

PHI Health, LLC v. Dale Martin Enterprises, No. 25 C 4181, 2025 WL 2930817 (N.D. Ill. Oct. 15, 2025) (Judge Sara L. Ellis). Plaintiff PHI Health, LLC filed this lawsuit in Illinois state court against defendants Dale Martin Enterprises, Inc. and Health Care Service Corporation seeking to recover compensation it asserts the defendants owe it for providing life-saving medical air ambulance services to insured patients. In its complaint, PHI Health asserts state law claims for breach of implied contract and unjust enrichment. In April, defendants removed the case to federal court on the basis of complete preemption under ERISA. In this decision the court ruled on PHI’s motion for remand and defendants’ motion to dismiss. The court applied the two-part analysis outlined by the Supreme Court in Davila to determine whether ERISA completely preempts the state law claims. Defendants argued that PHI is seeking to enforce rights that arise under ERISA. PHI disputed that the plan at issue is governed by ERISA and argued that it does not have standing to sue in any event. The court did not find it necessary to resolve these issues. Instead, it determined that the claims at issue implicate independent legal duties, making them outside of ERISA’s purview even assuming that the plan is governed by ERISA and that PHI could have brought its claims pursuant to Section 502(a)(1)(B). “PHI seeks to enforce its alleged contractual rights and recover benefits it claims DME has unjustly retained under Illinois state law, which are legal obligations that arise independent of ERISA.” As pleaded, the court agreed with the provider that its claims do not arise from the right to payment under the plan, and that its action neatly falls into the “rate of payment” category, rather than the “right to payment.” For these reasons, the court concluded that ERISA preemption under Section 502(a) does not apply. And, because the claims do not meet Davila’s test for complete preemption, the court found that PHI lacks standing under ERISA and the case cannot proceed in federal court. Accordingly, the court granted the motion to remand, and denied defendants’ motion to dismiss without prejudice to renewal in state court.

Medical Benefit Claims

First Circuit

Christine K. v. Blue Cross & Blue Shield of Rhode Island, No. 1:25-cv-00352-MSM-PAS, 2025 WL 2918382 (D.R.I. Oct. 14, 2025) (Judge Mary S. McElroy). Plaintiff Christine K. brings this ERISA action on behalf of herself and her minor child against Blue Cross & Blue Shield of Rhode Island and the Blue Cross & Blue Shield of Rhode Island Healthmate Coast-To-Coast Be Well Medical PPO Plan to obtain reimbursement for her child’s stay at Aspiro Wilderness Adventure Therapy for the treatment of mental health conditions. In her complaint Ms. K. asserts two related causes of action: (1) a claim for recovery of benefits and (2) a claim for equitable relief for violation of the Mental Health Parity and Addiction Equity Act. Defendants moved to dismiss the complaint for failure to state a claim pursuant to Federal Rule of Civil Procedure 12(b)(6). The court understood defendants’ motion as presenting two initial questions that needed to be resolved: whether the services provided by Aspiro were covered healthcare services under the plan, and if so, whether those services were nevertheless specifically excluded from coverage under the plan. To begin, the court was persuaded that Aspiro may be an “intermediate care service” within the meaning of the plan, and as a result, that Ms. K plausibly alleges it is a covered healthcare service. As to the thornier issue of whether Aspiro is excluded from coverage because it is a recreational therapy “wilderness program” as Blue Cross maintains, the court stated that it was “not prepared to make this determination based solely on the pleadings.” Rather, when faced with the parties’ “competing interpretations of the services provided by Aspiro and persuasive but non-binding findings from courts outside the First Circuit,” the court was satisfied that the facts viewed in the light most favorable to plaintiff do not support dismissal at this stage of the proceedings. Accordingly, the court denied defendants’ motion to dismiss in its entirety.

Pleading Issues & Procedure

Tenth Circuit

Salhoub v. Metropolitan Life Ins. Co., No. 25-2196-KHV, 2025 WL 2938995 (D. Kan. Oct. 16, 2025) (Judge Kathryn H. Vratil). Plaintiff Faleh Salhoub filed this lawsuit against Metropolitan Life Insurance Company (“MetLife”) under Sections 502(a)(1)(B) and 502(a)(3) of ERISA to challenge the insurer’s termination of his long-term disability benefits. Before the court was MetLife’s partial motion to dismiss the claim for equitable relief for breach of fiduciary duty under Section 502(a)(3). MetLife argued that the fiduciary breach claim is duplicative of the claim for benefits and that Mr. Salhoub cannot maintain both. While Mr. Salhoub conceded that if his remedy under Section 502(a)(1)(B) is adequate, he cannot obtain equitable relief for the same injury, he nevertheless argued that the complaint properly alleges alternative theories of liability. The court agreed. “Here, plaintiff pled alternative theories of liability: one for wrongful denial of benefits under the plan provisions and one for breach of fiduciary duty. Even if MetLife’s alleged breach of fiduciary duty led to its denial of benefits, plaintiff’s claim under Section (a)(3) is not duplicative because liability for breach of fiduciary duty ‘flows from the process, not the denial of benefits itself.’” Thus, at this stage the court was unwilling to ascertain whether Section 502(a)(1)(B) will provide Mr. Salhoub with an adequate recovery and instead allowed him to pursue recovery under both Sections 502(a)(1)(B) and (a)(3). As a result, the court denied MetLife’s motion to dismiss plaintiff’s claim for breach of fiduciary duty.

Remedies

Ninth Circuit

Oneto v. Watson, No. 22-cv-05206-AMO, 2025 WL 2899516 (N.D. Cal. Oct. 10, 2025) (Judge Araceli Martínez-Olguín). This action arises over a denial of health insurance coverage for a esophageal surgery plaintiff Roy Oneto needed to treat swallowing problems during a time when he was a participant in an employee welfare benefit plan administered by Cigna Health and Life Insurance Company. In his complaint Mr. Oneto alleges that he had to wait eight months before he ultimately underwent the surgery, after obtaining medical coverage through a different employer. The parties cross-moved for judgment on the two remaining causes of action against Cigna for breach of fiduciary duties and failure to discharge duties under the plan. Before ruling on the parties’ motions for judgment, the court first addressed their dispute over the proper Federal Rule of Procedure under which their motions should be resolved – Rule 52 or Rule 56. Mr. Oneto insisted that the court must consider the parties’ competing motions for judgment under Rule 56. However, the court did not agree. Instead, it determined that under Ninth Circuit precedent where, as here, the standard of review is for abuse of discretion, the court’s review is limited to the administrative record. Thus, the court concluded that the “the usual tests of summary judgment, such as whether a genuine dispute of material fact exists, do not apply.” The court then considered Cigna’s standing challenge to Mr. Oneto’s ability to recover on either of his causes of action. Cigna argued that Mr. Oneto is not entitled to any relief because his claimed injury is not redressable. The court concurred. “Here, Oneto’s claims for surcharge focus only on Cigna’s purported breach of duty. Oneto seeks to recover as compensatory surcharge the full value of the benefit initially denied by Cigna – $73,061.30 for the value of the surgery he did not receive as a result of Cigna’s purported malfeasance. However, the administrative record before the Court does not reveal that Oneto paid this amount. Indeed, Oneto did not pay for the eventual procedure, and he alleges that his subsequent employer covered the cost of the surgery. Therefore, even if Oneto established that Cigna breached a duty owed, the Court cannot grant the ‘make-whole’ relief requested because there exists no evidence of loss that resulted from a purported breach.” Mr. Oneto offered two alternative calculations of harm: (1) the amount he paid for the surgery under his subsequent insurer; or (2) his non-financial harm in the form of his physical suffering endured in the time between Cigna’s denial and his eventual procedure. But the court was forced to disregard both because there was no evidence of either in the administrative record. “Because Oneto cannot be awarded equitable surcharge on the record before the Court, his harms are not redressable by a favorable ruling. Consequently, he lacks standing and he cannot invoke the Court’s jurisdiction.” Thus, finding that Mr. Oneto lacks standing, the court dismissed his remaining ERISA claims and granted judgment in favor of Cigna.