Jody Rose v. PSA Airlines, Inc.

80 F.4th 488
Court of Appeals for the Fourth Circuit·Decided September 11, 2023·No. 21-2207·Published·Cited by 30 cases

Opinion

PUBLISHED

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

No. 21-2207

JODY ROSE, as Administratrix of the Estate of Kyree Devon Holman, Plaintiff - Appellant,

v.

PSA AIRLINES, INC.; PSA AIRLINES, INC. GROUP BENEFIT PLAN; UMR, INC.; QUANTUM HEALTH, INC., a/k/a MyQHealth by Quantum; MCMC, LLC,

Defendants - Appellees,

and

PSA AIRLINES GROUP INSURANCE PLAN; PSA AIRLINES GROUP HEALTH BENEFIT PLAN; PSA AIRLINES PLAN B EMPLOYEE BENEFIT PLAN; PSA AIRLINES SHARED SERVICES ORG.,

Defendants.

Appeal from the United States District Court for the Western District of North Carolina, at Charlotte. Graham C. Mullen, Senior District Judge. (3:19-cv-00695-GCM-DCK)

Argued: December 9, 2022 Decided: September 11, 2023

Before RICHARDSON, QUATTLEBAUM, and HEYTENS, Circuit Judges.

Affirmed in part, vacated in part, and remanded by published opinion. Judge Richardson wrote the opinion, in which Judge Quattlebaum joined. Judge Heytens wrote an opinion concurring in part and dissenting in part.

ARGUED: Norris Arden Adams, II, ESSEX & RICHARDS, P.A., Charlotte, North Carolina, for Appellant. Edward Joseph Meehan, GROOM LAW GROUP, CHARTERED, Washington, D.C.; Brian D. Boone, ALSTON & BIRD LLP, Charlotte, North Carolina, for Appellees. ON BRIEF: Caitlin Hale Walton, ESSEX RICHARDS, P.A. Charlotte, North Carolina, for Appellant. Ross P. McSweeney, GROOM LAW GROUP, CHARTERED, Washington, D.C., for Appellees PSA Airlines, Inc. and PSA Airlines, Inc. Group Benefit Plan. Brandon C.E. Springer, ALSTON & BIRD LLP, Charlotte, North Carolina, for Appellee UMR, Inc. Rachel Ann Smoot, TAFT STETTINIUS & HOLLISTER, LLP, Columbus, Ohio, for Appellee Quantum Health, Inc. Victoria Therese Kepes, Alfred Victor Rawl, Jr., GORDON REES SCULLY MANSUKHANI LLP, Charleston, South Carolina, for Appellee MCMC, LLC.

RICHARDSON, Circuit Judge:

The Employee Retirement Income Security Act’s § 502(a)(1)(B) allows a beneficiary to “recover benefits due to him under the terms of his plan.” And ERISA’s § 502(a)(3) allows a beneficiary to sue for “other appropriate equitable relief.” This case requires us to answer when—and under what conditions—a plaintiff may seek monetary relief under one of those provisions.

Jody Rose’s son had a rare heart condition. He died at the age of twenty-seven, awaiting a heart transplant, which Rose says that Defendants—who administered her son’s employer-based health benefits program—wrongfully denied. So she sued on behalf of his estate, seeking monetary relief under both § 502(a)(1)(B) and § 502(a)(3). The district court dismissed both claims. As to Rose’s (a)(1)(B) claim, the court held that money was not one of the “benefits” that her son was owed “under the terms of his plan.” And, as to her (a)(3) claim, the court held that her requested monetary relief was too similar to money damages and was thus not “equitable.”

We now affirm in part and vacate in part. The district court correctly held that money was not one of the “benefits” that Rose’s son was “due” “under the terms of his plan.” So it was right to dismiss her (a)(1)(B) claim. But we must vacate its complete dismissal of Rose’s (a)(3) claim. While the district court correctly noted that compensatory, “make-whole” monetary relief is unavailable under § 502(a)(3), it did not consider whether Rose plausibly alleged facts that would support relief “typically” available in equity. Montanile v. Bd. of Trs., 577 U.S. 136, 142 (2016). We thus remand for the district court to decide in the first instance whether Rose can properly allege such a

theory based on a Defendant’s unjust enrichment, including whether an unjust gain can be followed to “specifically identified funds that remain in the defendant’s possession” or to “traceable items that the defendant purchased with the funds.” Id. at 144–45 I. Factual and Procedural Background It was Christmas Eve in 2018 when Rose’s son, Kyree Devon Holman, first found out that he had a heart condition called myocarditis. Less than two months later—and only a few short weeks after his twenty-seventh birthday—he was dead.

At the time, Kyree was working as a flight attendant for PSA Airlines, Inc. Like many Americans, Kyree received health benefits through his employer. PSA Airlines runs a “health and welfare benefit plan” for its employees, governed by ERISA. J.A. 13. The Plan is “fully self-funded,” meaning that PSA Airlines “assumes the sole responsibility for funding the Plan benefits out of its general assets.” J.A. 13. PSA Airlines is the named “Plan Administrator” and “fiduciary” of the Plan. J.A. 14. But a smattering of other companies—including UMR, Inc., Quantum Health, Inc., and MCMC, LLC—help PSA Airlines provide administrative services, like reviewing benefits claims, for the Plan. 1 When doctors discovered Kyree’s health condition, they determined that he needed a heart transplant to survive and prepared to proceed with surgery as soon as his benefits claim was approved. By the second week of January 2019, Kyree’s doctors had submitted the required information and had twice requested approval for the surgery. Yet, on January

1

The Plan’s terms are not themselves in the record. But because we are at the pleading stage, our characterization of the Plan’s terms—like all the facts that we recount here—are taken from Rose’s complaint, read in the light most favorable to her.

17, Defendants denied his request, asserting that the treatment that he sought was experimental. When Kyree pushed for a re-evaluation, his claim was once again denied, this time on the grounds that he did not meet certain alcohol-abuse criteria.

The terms of Kyree’s plan, however, contained no such criteria. So Kyree’s doctors appealed once more, noting that Kyree would not survive without a heart transplant. But once more—despite realizing the life-or-death nature of the decision—Defendants denied Kyree’s request, based on these same supposed criteria.

By now it was February 1, and time was running short. Kyree’s doctors thus sought an “expedited” external claim review, which was conducted by MCMC. Yet, although federal law requires “expedited” reviews to be completed within—at most—seventy-two hours, see 45 C.F.R. § 147.136(d)(3)(iv) (2019), MCMC treated Kyree’s review as a “standard” review to be completed within forty-five days. Kyree died a little over a week after submitting his external review application (five days after a decision should have been rendered). Ultimately, after completing its review on March 6, MCMC vindicated Kyree, overturning the previous claim denials. But it was too little, too late: By then, Kyree had been dead for almost a month.

Rose, as administratrix of Kyree’s estate, sued PSA Airlines, the Plan, UMR, Quantum, and MCMC, seeking relief for a wrongful denial of benefits under ERISA § 502(a)(1)(B) or, alternatively, for a breach of fiduciary duty under § 502(a)(3). 2 She

2

Subparagraph 502(a)(1)(B) and § 502(a)(3) of ERISA are codified at 29 U.S.C.

§ 1132(a)(1)(B) and (a)(3), respectively. But, in keeping with the trend in this practice area, we refer to them and the other statutory provisions by their ERISA designation, not by their place in the U.S. Code.

sought declaratory and injunctive relief, monetary damages, and “appropriate equitable relief” including “surcharge, disgorgement, constructive trust, restitution, [and] equitable estoppel.” J.A. 40–41. But the district court granted Defendants’ motion to dismiss both claims under Rule 12(b)(6). Rose timely appealed that dismissal, which we review de novo. See Mays v. Sprinkle, 992 F.3d 295, 299 (4th Cir. 2021). II. Background on ERISA ERISA governs “employee benefit plans” that cover employees’ retirement benefits, death benefits, and, as relevant for this case, health benefits. ERISA has a host of provisions, one of which imposes fiduciary duties on those who administer these plans. See Varity Corp. v. Howe, 516 U.S. 489, 496 (1996).

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Jody Rose v. PSA Airlines, Inc., 80 F.4th 488 (4th Cir. 2023).

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