Illinois State Bar Center on Kenseth v. Dean Health Plan, Inc.
By : LGoldman | Category : Decisions, News | No Comments
13th Jun 2013
Dist. Ct. erred in granting defendant health benefits plan’s motion for summary judgment in ERISA action, alleging that defendant breached fiduciary duty to plaintiff-plan participant where plaintiff alleged that defendant failed to provide her with procedure through which she could obtain authoritative pre-approval for her surgery to correct problems associated with prior weight-loss surgery, under circumstances where plaintiff underwent surgery after receiving oral representative that said surgery would be covered under plan, but was informed after surgery that said surgery would not be covered under plan. While basis for Dist. Ct.’s order was finding that plaintiff could not seek monetary recovery for instant equitable claim under section 1132(a)(3) of ERISA, Supreme Ct. decision in Cigna, 131 SCt 1866 would allow plaintiff ability to seek monetary “surcharge” from defendant upon showing of actual harm arising out of breach if she could show on remand that defendant failed to alert her that she could not rely on advice that surgery was covered under plan, and that said advice lulled her into failing to obtain either alternative coverage or alternative treatments.
Federal 7th Circuit Court
June 13, 2013
Vacated and remanded