Health Administration Responsibility Project
[Maura Larkins comment: I suggest clicking on the link above to see the ENTIRE
original article with lots of links in it!]
If the Managed Care Organization is "related to" an Employee Benefit Plan (EBP), the
requirements of ERISA, the Employee Retirement Income Security Act of 1974, and its
regulations are of overriding importance, and severely restrict patient rights.
No employer is obligated to establish an EBP. In order to encourage them to do so,
Congress has given them, their plans, their HMOs and Insurers, and their administrators
substantial immunities from liability.
State Regulation of HMOs administered by self-insured EBPs is Preempted by ERISA, so
employees cannot be protected by those state laws which limit the excesses of other HMOs,
not subject to ERISA.
Any case 'relating to' an EBP falls under Federal Jurisdiction and may be removed from
state to federal court.
There the patient will find that the usual state law Tort Claims are also preempted by ERISA,
so any claims against the HMO or EBP for medical malpractice, wrongful death, fraud, etc.
will be summarily dismissed.
True, he may sue for a benefit denied him, but the decision of the plan
administrator may often be reversed only if it was found to have been Arbitrary
and Capricious, a very difficult standard to meet... [Maura Larkins comment:
Sometimes it might not be so difficult to prove. See Kaiser urology shenanigans.]
LaRUE v. DeWOLFF, BOBERG & ASSOCIATES, INC., et al.
certiorari to the united states court of appeals for the fourth circuit
No. 06–856. Argued November 26, 2007—Decided February 20, 2008
450 F. 3d 570, vacated and remanded.
[Professor Shaun Martin assisted in the successful briefing and argument of LaRue v.
DeWolff, Boburg & Associates, 128 S.Ct. 1020 (2008), an ERISA benefits case.]
Petitioner, a participant in a defined contribution pension plan, alleged that the plan
administrator’s failure to follow petitioner’s investment directions “depleted” his interest in the
plan by approximately $150,000 and amounted to a breach of fiduciary duty under the
Employee Retirement Income Security Act of 1974 (ERISA). The District Court granted
respondents judgment on the pleadings, and the Fourth Circuit affirmed. Relying on
Massachusetts Mutual Life Ins. Co. v. Russell, 473 U. S. 134 , the Circuit held that ERISA
§502(a)(2) provides remedies only for entire plans, not for individuals.
Held: Although §502(a)(2) does not provide a remedy for individual injuries distinct from plan
injuries, it does authorize recovery for fiduciary breaches that impair the value of plan assets
in a participant’s individual account. Section 502(a)(2) provides for suits to enforce the
liability-creating provisions of §409, concerning breaches of fiduciary duties that harm plans.
The principal statutory duties imposed by §409 relate to the proper management,
administration, and investment of plan assets, with an eye toward ensuring that the benefits
authorized by the plan are ultimately paid to plan participants. The misconduct that
petitioner alleges falls squarely within that category, unlike the misconduct in Russell. There,
the plaintiff received all of the benefits to which she was contractually entitled, but sought
consequential damages arising from a delay in the processing of her claim. Russell’s
emphasis on protecting the “entire plan” reflects the fact that the disability plan in Russell,
as well as the typical pension plan at that time, promised participants a fixed benefit.
Misconduct by such a plan’s administrators will not affect an individual’s entitlement to a
defined benefit unless it creates or enhances the risk of default by the entire plan. For
defined contribution plans, however, fiduciary misconduct need not threaten the entire plan’
s solvency to reduce benefits below the amount that participants would otherwise receive.
Whether a fiduciary breach diminishes plan assets payable to all participants or only to
particular individuals, it creates the kind of harms that concerned §409’s draftsmen. Thus,
Russell’s “entire plan” references, which accurately reflect §409’s operation in the defined
benefit context, are beside the point in the defined contribution context. Pp. 4–8.
450 F. 3d 570, vacated and remanded.
Stevens, J., delivered the opinion of the Court, in which Souter, Ginsburg, Breyer, and Alito,
JJ., joined. Roberts, C. J., filed an opinion concurring in part and concurring in the judgment,
in which Kennedy, J., joined. Thomas, J., filed an opinion concurring in the judgment, in
which Scalia, J., joined.
Kaiser Permanente links