INTRODUCTION TO ERISA
WELFARE BENEFIT CLAIMS
Jonathan M. Feigenbaum
Phillips & Angley
One Bowdoin Square
Boston, MA 02114
617-367-8787
JonF@phillips-angley.com
www.phillips-angley.com
ERISA
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On September 2, 1974 (Labor Day)
Congress enacted the Employee
Retirement Income Security Act (ERISA).
Although the statute uses the word
retirement in its title, ERISA governs both
retirement benefits (pensions) and
employee welfare benefit plan. Those are
benefits that private sector employers
provide to employees; government
employees and those employed by
churches are not subject to ERISA.
The History Behind ERISA.
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Originally drafted with pension plans in mind,
over time ERISA has come to govern much
more. Part of the concept behind ERISA was to
create a uniform law for employee benefits and
pensions nationwide. This was thought to
protect employees and to make it more
reasonable for employers that operated in many
states. Rather than dealing with 50 different
state laws, employers would be governed by one
Federal law
The Two Sides of ERISA.
1. PENSION
-Defined Benefit Plans
-Defined Contribution Plans
2. WELFARE BENEFIT PLANS
-Disability Plans
-Health Plans
ERISA Protects
Employees, right?
This must be good for
employees!
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It is hereby declared to be the policy of this
chapter to protect interstate commerce and the
interests of participants in employee benefit
plans and their beneficiaries, by requiring the
disclosure and reporting to participants and
beneficiaries of financial and other information
with respect thereto, by establishing standards
of conduct, responsibility and obligation for
fiduciaries of employee benefit plans, and by
providing for appropriate remedies, sanctions,
and ready access to the Federal courts. ERISA
Sec. 2., 29 U.S.C. 1001(b)
ADAM
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A 16th Century Interpretation of Adam
Is ERISA That Good.
Absolutely Not!
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"Everything Ridiculous Imagined Since
Adam. This court does not take so dim a
view of the Employee Retirement Income
Security Act of 1974. Instead, this court is
willing to believe that ERISA has lurking
somewhere in it a redeeming feature.
Florence Nightingale Nursing Service,
Inc. v. Blue Cross/Blue Shield of Alabama,
832 F.Supp. 1456, 1457 (N.D.Ala. 1993).
ERISA – How Does It Work?
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ERISA is truly a creature of its own. It ‘s a
blend of:
trust law
contract law
disability insurance law
Health insurance law
federal common law of its own
ERISA PREEMPTION, IT DOESN’T
GET MUCH BROADER
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Section 514(a) of ERISA states that the
statute "shall supersede any and all State
laws insofar as they may now or hereafter
relate to any employee benefit plan" that is
covered by ERISA. Section 514(b)(2)(A)
The Savings Clause
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29 U.S.C. § 1144(a). The saving clause
states as follows:
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Except as provided in subparagraph (B)
[the deemer clause], nothing in this
subchapter shall be construed to exempt
or relieve any person from any law of any
State which regulates insurance, banking,
or securities.
The Deemer Clause
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29 U.S.C. § 1144(b)(2)(A). The deemer clause
states as follows:
Neither an employee benefit plan... nor any trust
established under such a plan, shall be deemed
to be an insurance company or other insurer,
bank, trust company, or investment company or
to be engaged in the business of insurance or
banking for purposes of any law of any State
purporting to regulate insurance companies,
insurance contracts companies., banks, trust
companies, or investment
The Genesis of the Trouble
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Referring to ERISA as a carefully
“reticulated statute.”
"Pilot Life Ins. Co. v. Dedeaux,, 481 U.S.
41, 54 (1987).
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[T]he detailed provisions of 502(a) set forth a
comprehensive civil enforcement scheme that represents
a careful balancing of the need for prompt and fair
claims settlement procedures against the public interest
in encouraging the formation of employee benefit plans.
The policy choices reflected in the inclusion of certain
remedies and the exclusion of others under the federal
scheme would be completely undermined if ERISA-plan
participants and beneficiaries were free to obtain
remedies under state law that Congress rejected in
ERISA. 'The six carefully integrated civil enforcement
provisions found in 502(a) of the statute as finally
enacted ... provide strong evidence that Congress did not
intend to authorize other remedies that it simply forgot
to incorporate expressly.' "Dedeaux, 481 U.S. at 54.
The Hidden Menace.
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Would a reasonable employer pay
premiums to an insurer if that employer
really understood how long term disability
benefits are calculated and paid? Would
an employee make a partial or full
payment toward the premium?
The Curses of ERISA.
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No Jury Trial
No Damages – All actions are equitable
No Consequential Damages
No Punitive Damages
No Make Whole Remedies
Federal Court Jurisdiction
Almost Suspension of Fed. Rules of Civil Procedure
Extremely Difficult Burden to Obtain Discovery
Rarely Live Testimony
Claims Usually Decided on Cross Motions
Insurers are treated as fiduciaries and their decisions will only be
overturned if “arbitrary and capricious,” not just unfair or
probably wrong
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Semien v. Life Ins. Co. of
America, 436 F.3d 805, 815 (7th
Cir. 2006).
Congress has not provided
Article III courts with the
statutory authority, nor the judicial resources, to engage
in a full review of the motivations behind every plan
administrator's discretionary decisions. To engage in
such a review would usurp plan administrators'
discretionary authority and move toward a costly system
in which Article III courts conduct wholesale
reevaluations of ERISA claims. Imposing onerous
discovery before an ERISA claim can be resolved would
undermine one of the primary goals of the ERISA
program: providing "a method for workers and
beneficiaries to resolve disputes over benefits
inexpensively and expeditiously." Perry v. Simplicity
Eng'g, 900 F.2d 963, 967 (6th Cir. 1990) (internal
citation omitted).
The Nightmare, offsets and other
recoveries.
Who wants reimbursement?
-Health Plan
-Comp Insurer
-LTD Insurer
-All or some of the above.
What Does One Do?
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Read the documents.
Plan Ahead.
Advise your client well.
Get other counsel involved as necessary.
Negotiate a settlement that that your client
can accept.
Tell your client about the nightmare of ERISA.
Fight back!
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Help your clients achieve
justice. Sleep well at night!