W.A. Griffin v. Teamcare
909 F.3d 842
7th Cir.
2018

Background

  • Dr. W.A. Griffin (assignee of patient T.R.) is a dermatologist who treated T.R., a participant in a Central States health plan administered under ERISA. Blue Cross Blue Shield was plan third‑party administrator.
  • T.R. assigned Griffin rights to pursue claims for benefits and penalties; a Central States representative told Griffin the plan would pay at the usual, reasonable, and customary (U&C) rate per plan §11.09.
  • Griffin submitted a $7,963 claim; Central States paid part of it, allegedly underpaying by $5,014. Griffin requested plan documents (SPD, fee schedules/rate tables, Data iSight materials) and appealed the underpayment.
  • Central States responded after six months, stating Data iSight used a “pricing methodology” and suggested negotiating with Data iSight; it provided the SPD but not fee schedules or Data iSight materials. Griffin alleges appeals were effectively exhausted.
  • Griffin sued under ERISA: Count 1 for unpaid benefits (29 U.S.C. §1132(a)(1)(B)); Count 2 for breach of fiduciary duty (29 U.S.C. §1132(a)(3)); Count 3 for statutory penalties for failure to produce plan documents (29 U.S.C. §§1024(b)(4), 1132(c)(1)). The district court dismissed all counts; this appeal followed.

Issues

Issue Plaintiff's Argument Defendant's Argument Held
Whether Griffin adequately pleaded a claim for unpaid benefits under §1132(a)(1)(B) Griffin alleged plan coverage (representative’s assurance), payment was made but under U&C rate per §11.09, and she was underpaid — need not plead exact plan text Must identify specific plan provision that confers entitlement to the higher reimbursement Reversed: pleading need not quote specific plan language when facts plausibly show coverage and underpayment; Count 1 survives dismissal
Whether equitable relief for breach of fiduciary duty under §1132(a)(3) is available Griffin asserted fiduciary breach for not following plan terms Central States argued duplicative of benefits claim Affirmed dismissal: equitable relief unavailable where §1132(a)(1)(B) provides adequate relief; Count 2 dismissed
Whether an assignee may seek statutory penalties under §1132(c)(1) for failure to produce plan documents Griffin (as assignee) argues she is a beneficiary entitled to requested plan information and penalties when not timely provided Central States contended assignee is not entitled to penalties; also argued it provided SPD and thus no penalty due Reversed in part: assignee can be a beneficiary for penalties; SPD was provided late (after 30 days) and Data iSight materials constituted pricing methodology (should have been produced); claim for penalties as to those materials survives
Whether failure to exhaust administrative remedies defeats Griffin’s benefits claim Griffin alleges appeals process was illusory and delay excused exhaustion Central States argued exhaustion required Not decided: exhaustion defense waived on appeal; district court should consider on remand if properly raised

Key Cases Cited

  • Allen v. GreatBanc Tr. Co., 835 F.3d 670 (7th Cir. 2016) (standard of review and pleading law under ERISA)
  • Clair v. Harris Tr. & Sav. Bank, 190 F.3d 495 (7th Cir. 1999) (plan language required for benefit entitlement)
  • Innova Hosp. San Antonio, Ltd. P'ship v. Blue Cross & Blue Shield of Ga., Inc., 892 F.3d 719 (5th Cir. 2018) (plaintiffs need not plead exact plan language to survive dismissal)
  • Hess v. Hartford Life & Accident Ins. Co., 274 F.3d 456 (7th Cir. 2001) (plan administrators cannot randomly pay benefits to those not entitled)
  • Varity Corp. v. Howe, 516 U.S. 489 (1996) (§1132(a)(3) equitable relief available only when §1132(a)(1) does not provide relief)
  • Mondry v. Am. Family Mut. Ins. Co., 557 F.3d 781 (7th Cir. 2009) (disclosure of plan calculation bases required for meaningful appeal)
  • Neuma, Inc. v. AMP, Inc., 259 F.3d 864 (7th Cir. 2001) (assumption that assignees might be entitled to penalties under §1132(c)(1))
  • Kennedy v. Conn. Gen. Life Ins. Co., 924 F.2d 698 (7th Cir. 1991) (assignee who is designated to receive benefits is treated as beneficiary for suing for unpaid benefits)
  • Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (disclosure ensures participant knows where he stands with respect to plan)
  • Mueller v. Apple Leisure Corp., 880 F.3d 890 (7th Cir. 2018) (court may consider plan document attached to motion to dismiss when central to claim)
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