Summary
In this ERISA case, the Seventh Circuit held that an assignee of a plan participant is a "beneficiary" eligible to seek statutory penalties under 29 U.S.C. § 1132(c)(1) for failure to produce plan documents, including fee schedules and rate tables used to calculate benefits. The court also ruled that a plaintiff adequately states a claim for unpaid benefits under § 1132(a)(1)(B) by alleging the plan covered the services and underpaid, without needing to plead specific plan provisions. The breach of fiduciary duty claim under § 1132(a)(3) was properly dismissed as duplicative of the benefits claim. The district court's dismissal of Count 2 was affirmed, but dismissal of Counts 1 and 3 was vacated and remanded.
Topics
Practice areas
Questions Presented
- Whether the district court erred in dismissing the claim for unpaid benefits under 29 U.S.C. § 1132(a)(1)(B) for failure to identify a specific plan provision establishing coverage.
- Whether the district court erred in dismissing the breach of fiduciary duty claim under 29 U.S.C. § 1132(a)(3) as duplicative of the benefits claim.
- Whether an assignee of a plan participant qualifies as a beneficiary under ERISA to seek statutory penalties under 29 U.S.C. § 1132(c)(1) for failure to furnish plan documents, and whether the specific documents requested were required.
Holdings
- Plaintiffs need not identify the specific plan provision at the pleading stage; it is sufficient to allege that the plan covered the services and that the amount paid was less than what the plan promised.
- The breach of fiduciary duty claim is duplicative because § 1132(a)(1)(B) provides an adequate remedy, so equitable relief under § 1132(a)(3) is not available.
- An assignee who receives a plenary assignment of rights is a beneficiary and may sue for statutory penalties under § 1132(c)(1).
- Dr. Griffin stated a claim for the summary plan description (delayed response) and the pricing methodology documents (Data iSight's fee schedules and rate tables), but not for the contract with Blue Cross Blue Shield because she did not request it.
Factual background
Dr. Griffin, a dermatologist and surgeon, provided medical care to T.R., a participant in a Central States health plan. T.R. assigned to Dr. Griffin the rights under the plan to pursue claims for benefits, statutory penalties, and breach of fiduciary duty. Dr. Griffin confirmed with a Central States representative that the plan would pay her at the usual, reasonable, and customary rate as provided in section 11.09 of the plan. She treated T.R. and submitted a claim for $7,963, but Central States underpaid her by $5,014. She challenged the benefits determination and requested plan documents, but after six months received only a partial response.
Procedural history
The district court granted the motion to dismiss all three counts of the complaint. Dr. Griffin appealed.
Remand instructions
Remand Counts 1 and 3 for further proceedings consistent with the opinion, including consideration of the affirmative defense of exhaustion if raised.