In Administrative Committee of the Wal-Mart Stores, Inc. v. Gamboa, 479 F.3d 538 (8th Cir. 2007), an ERISA plan administrator brought suit seeking equitable reimbursement from a plan participant who had received a settlement from a tortfeasor. Although the reimbursement provision was contained in an SPD for a health plan, the employer had no formal written health plan. Reversing summary judgment for the participant, the Eighth Circuit held that the plan administrator reasonably construed the SPD to be on the plan document for purposes of a group health plan in the absence of any formal plan and that the reimbursement provision in the SPD was therefore enforceable.In Negley v. Breads of the World Medical Plan, 222 F. App’x 692 (10th Cir. 2007), plaintiff brought a claim under § 502(a)(3) of ERISA to recover medical expenses that were not covered by his health insurance plan. Because of his late enrollment in the plan, certain of plaintiff’s medical expenses were excluded as preexisting conditions. Plaintiff argued that the plan breached its fiduciary duties to promptly distribute health plan enrollment materials and to advise of enrollment deadlines. The Tenth Circuit found plaintiff’s claim for monetary damages unavailable under § 502(a)(3) and refused to grant plaintiff the “equitable remedy” he sought: an order retroactively changing his enrollment date. The court lacked authority to “antedate the actual performance of an act, to supply facts which never existed, or to embody a fiction that something which never happened did actually occur.”

In Rogozinski v. Hartford Life & Accident Insurance Co., 2007 WL 2409810 (N.D. Ill. Aug. 21, 2007), after finding that Hartford properly terminated plaintiff’s disability benefits, the court, relying on Sereboff v. Mid Atlantic Medical Services, Inc., entered summary judgment for Hartford on its § 502(a)(3) equitable counterclaim for reimbursement of benefits that plaintiff received from the Social Security Administration and another insurer. Agreeing with Hartford that the plan’s “Other Income Benefit” provision created an equitable lien by agreement the moment plaintiff received money that he was obligated to repay under this provision, the court found that Sereboff compelled plaintiff to repay to Hartford the benefit payments he received from Hartford that were duplicative of the amounts he received from the Social Security Administration and the other insurer.

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This entry was posted by Adam V. Russo on Tuesday, July 28th, 2009 at 8:54 am and is filed under 10th, 7th, 8th, Fiduciary Liability, Plan Language, Summary Plan Description. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.