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The Wagner Law Group

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established in 1996, The Wagner Law Group has 25 attorneys engaged exclusively in employee benefits, estate planning and employment law. Six of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Boston 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Palm Beach Gardens 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

Tampa

Tel: (813) 603-2959

Fax: (813) 603-2961

101 East Kennedy Boulevard

Suite 2140
Tampa, FL  33602 

 

San Francisco

Tel: (415) 625-0002

Fax: (415) 358-8300

300 Montgomery Street

Suite 600

San Francisco, CA 94104

 

St. Louis

Tel: (314) 236-0065

Fax: (314) 236-5743
100 South 4th Street, Suite 550
St. Louis, MO  63102 

 

www.wagnerlawgroup.com

 

 

 

 

September 29, 2016

 

 Health and Welfare Law Alert

 

 

 

   State Law May Prohibit Discretionary Clauses in ERISA-covered Plans

 

 

 

 

 

Despite ERISA's preemption clause, a federal district court has upheld, in Thomas vs. Aetna Life insurance Co., a California law prohibiting discretionary clauses in ERISA-covered plans.

 

Background. An employee in California was injured in an automobile accident and applied for benefits under her employer's self-funded short term disability plan. The plan administrator denied the benefit and the employee sued.

 

At trial, the two sides clashed over what the appropriate standard of review for the case should be. Generally, the default standard of review for benefit denials in an ERISA-covered plan is a "de novo" standard of review, which means that a court will independently review a claim and not defer to the plan administrator's, or insurer's, decision. However, if the plan document (or insurance contract) grants discretionary authority to determine benefit entitlement, the court applies a less-demanding "arbitrary and capricious" standard of review, which means that the plan's or insurer's decision will be upheld unless it is determined to be arbitrary and capricious. 

 

The disability plan at issue contained a discretionary clause that provided the plan administrator with "the discretion and authority to interpret and construe the provisions of the STD plan.. [and] decide any dispute which may arise with regard to the rights of Participants entitled to benefits." However, a California law says "[I]f a policy, contract, [or] certificate... that provides or funds life insurance or disability insurance coverage for any California resident contains a provision that reserves discretionary authority... to determine eligibility for benefits or coverage.... that provision is void and unenforceable."

 

District Court Decision. At trial, the plan administrator agued that this law was preempted by ERISA because, with certain exceptions such as insurance laws, ERISA is meant to "supersede any and all State laws insofar as they relate to any employee benefit plan." Because this plan was self-insured the administrator said that the California law could not be applied.

 

The district court first said that the law could apply to a self-funded plan because the California law purported to cover "contracts" and not just insurance policies. It stated that "[A]n ERISA plan is a contract."

 

In the Supreme Court decision in Gobeille (see the Alert of 3/9/14), the Court had said that ERISA preempts two categories of state laws: "(1) where a state's law acts immediately and exclusively upon ERISA plans and (2) where a state law has an 'impermissible connection' with ERISA plans." The district court determined that neither of these categories applied to the instant case. It explained that the first category did not apply because the California law did not act exclusively on ERISA plans. Regarding the second category, the court said that "the initial decision made by a plan administrator to deny or grant disability benefits is a technical medical decision based on the evidence before the administrator. Whether that decision will be subject to de novo or discretionary review should not impact the administrator's decision..." 

 

Ultimately, the court ruled that state laws such as the California law, whether applied to self-funded plans or not, do not govern a central matter of plan administration or interfere with nationally uniform plan administration.; therefore, they do not have an "impermissible connection" to ERISA plans. Accordingly, the court concluded that the California law was not preempted and that it will review the plan administrator's claims decision under the stricter de novo standard.

 

 

 

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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.