erisa and life insurance news

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“Benefit-Stripping” Amendment to ERISA Plan Is Permissible in Context of Welfare Benefits ERISA & LIFE INSURANCE NEWS Covering ERISA and Life, Health and Disability Insurance Litigation INSIDE THIS ISSUE 05 06 07 08 09 10 continued on page 2 >> 04 AUGUST 2014 Pulmonary Irritants Unique to Employee’s Work Site Did Not Support Disability from Her Occupation Employer Was Not Acting as an ERISA Fiduciary When It Accepted Premiums from Plan Participant Divorce Decree Must Describe Life Insurance with Sufficient Specificity Agent’s Fraudulent Concealment of Terminal Illness Resulted in Rescission of Policy Insuring His Brother State Law Claims of Breach of Contract and Fraud Dismissed Because Completely Preempted by ERISA Benefits Decision Was Not Arbitrary Because It Was Supported By Evidence Inconsistent With Insured’s Claim Former Employee Had Right as ERISA Plan “Participant” to Request Copy of SPD 11 A prime objective of ERISA is to protect the rights of employees to receive retirement benefits which have become vested, based on the attainment of retirement age, or years of service, or other criteria established by an employer’s plan. To accomplish that objective, pension plans are required by Section 203 of ERISA, 29 U.S.C. § 1053, to include provisions that prevent the forfeiture of accrued benefits. In the context of pension plans, the protection of vested benefits is explicit in the statute and is enforced in the case law. But what about benefits that have accrued under welfare benefit plans, such as disability benefits that an employee has been receiving for years? Can a welfare plan change the rules and terminate benefits that have already been awarded, based on a “benefit-stripping” amendment to the plan? Beneficiary’s Agreement with Insurer’s Agent Did Not Prevent Lapse of Life Policy

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Smith Moore Leatherwood's quarterly newsletter covering ERISA and Life, Health and Disability Insurance Litigation.

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Page 1: ERISA and Life Insurance News

“Benefit-Stripping” Amendmentto ERISA Plan Is Permissible in Context of Welfare Benefits

ERISA & LIFE INSURANCE NEWSC o v e r i n g E R I S A a n d L i f e , H e a l t h a n d D i s a b i l i t y I n s u r a n c e L i t i g a t i o n

INSIDE THIS ISSUE

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AUGUST

2014

Pulmonary Irritants Unique to Employee’s Work Site Did Not Support Disability from Her Occupation

Employer Was Not Acting as an ERISA Fiduciary When It Accepted Premiums from Plan Participant

Divorce Decree Must Describe LifeInsurance with Sufficient Specificity

Agent’s Fraudulent Concealment of Terminal Illness Resulted in Rescission of Policy Insuring His Brother

State Law Claims of Breach of Contract and Fraud Dismissed Because Completely Preempted by ERISA

Benefits Decision Was Not Arbitrary Because It Was Supported By Evidence Inconsistent With Insured’s Claim

Former Employee Had Right as ERISA Plan “Participant” to Request Copy of SPD

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A prime objective of ERISA is to protect the rights of employees to receive retirement benefits which have become vested, based on the attainment of retirement age, or years of service, or other criteria established by an employer’s plan. To accomplish that objective, pension plans are required by Section 203 of ERISA, 29 U.S.C. § 1053, to include provisions that prevent the forfeiture of accrued benefits.

In the context of pension plans, the protection of vested benefits is explicit in the statute and is enforced in the case law. But what about benefits that have accrued under welfare benefit plans, such as disability benefits that an employee has been receiving for years? Can a welfare plan change the rules and terminate benefits that have already been awarded, based on a “benefit-stripping” amendment to the plan?

Beneficiary’s Agreement with Insurer’s Agent Did Not Prevent Lapse of Life Policy

Page 2: ERISA and Life Insurance News

2 | ERISA and Life Insurance News | August 2014

No Vesting for Welfare Benefits

As long as the plan provides a process for amendment, and if that process is followed, the answer is yes – such benefits can be terminated. Just as ERISA does not require an employer to provide any welfare benefits, the statute also does not impose vesting requirements for welfare benefits.

That result was reached in Price v. Board of Trustees of the Indiana Laborer’s Pension Fund, 707 F.3d 647 (6th Cir. 2013), which involved a multi-employer plan providing both pension and welfare benefits. The plan document granted discretionary authority to a Board of Trustees to administer benefits, including the right to amend the plan.

The plan document provided, however, that “no amendment shall be made which results in reduced benefits for any

Participant whose rights have already become vested under the provisions of the Plan on the date the amendment is made, except upon the advice and counsel of an enrolled actuary.”

The plaintiff, Price, began receiving disability benefits under the plan in 1990 as the result of work-related injuries. Eleven years later, in 2001, Price was informed that he no longer qualified for benefits under the plan’s “Total and Permanent Disability Benefit” category, but that his benefits would continue under the “Occupational Disability Benefit” category, which provided that benefits could continue until he reached Early Retirement Age.

Plan Amendment

Three years later, in 2004, the Board of Trustees amended the plan, providing that disability benefits that became

payable before January 1, 2005, under the “Occupational Disability Benefit” category, would be discontinued effective December 31, 2006.

Price appealed the termination of his benefits, but his appeal was denied by the Board, relying on its authority to amend the plan. Price then sued, alleging that the 2004 amendment violated ERISA because it deprived him of a vested benefit.

Applying a de novo standard of review, the district court granted summary judgment to Price. 2009 WL 799639 (S.D. Ohio Mar. 24, 2009). The Sixth Circuit reversed, holding that because the Board of Trustees had discretion to interpret the plan, the arbitrary and capricious standard should have been applied. 632 F.3d 288 (6th Cir. 2011).

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Smith Moore Leatherwood LLP | Attorneys at Law | 3

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On remand, the district court again ruled in favor of Price. The case was appealed again, and again the Sixth Circuit reversed. The appellate court began its analysis with this familiar statement:

ERISA does not create a substantive right to welfare benefits – such as occupational disability benefits – nor does ERISA establish a vesting requirement for welfare benefits. Indeed, a welfare benefit may be terminated at any time so long as the termination is consistent with the terms of the plan.

707 F.3d at 651 (internal citations omitted). Price relied on the plan’s provision that no amendment could be made which resulted in reduced benefits for any plan participant “whose rights have already become vested.” The court concluded that this provision was ambiguous, but it held that the Board of Trustees reasonably exercised its discretion to interpret the provision.

“[T]he term ‘vesting’ in the Plan plainly

refers to retirement-related, not disability-related benefits,” the court said. “For these reasons, the Board’s interpretation was reasonable, and as a result, the decision was not arbitrary and capricious.” Id. at 652.

...a welfare benefit may be terminated at any time so long

as the termination is consistent with

the terms of the plan.

The Sixth Circuit held that the amendment was valid and that the Board of Trustees was entitled to judgment as a matter of law, as a result of which Price was not entitled to additional benefits, although he would not reach Early Retirement Age for several years.

Dissenting Opinion

In a dissenting opinion, a district judge, sitting by designation, wrote that Price’s rights should be governed by the plan document that was in effect when his benefits were awarded, not by the amendment that retroactively terminated those benefits.

“Certainly the Plan has the power to change prospectively the terms on which it offers benefits to Plan participants who have not qualified to receive those benefits,” the dissent said. “But it is, in my view arbitrary and capricious for the Plan to terminate benefits that have already been awarded based on a retroactive benefit-stripping amendment.”

This decision illustrates several important ERISA principles. First, the plan document controls the rights of plan participants. Second, so long as vested pension benefits are not forfeited, a plan is not cast in stone, but can be amended, provided the plan document provides the right to amend and the procedure for amending the plan is followed. Third, decisions made by plan fiduciaries exercising discretionary authority should be upheld, provided the decision – in this case, one of plan interpretation – did not result from an abuse of discretion.

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Beneficiary’s Agreement with Insurer’s Agent Did Not Prevent Lapse of Life PolicyFidelity & Guaranty Life Ins. Co. v. Thomas, 559 F. App’x 803 (11th Cir. Mar. 11, 2014)

Carol Thomas was the beneficiary of a policy insuring the life of her husband, Stillman Cook. The policy provided that it would terminate if a premium was not paid within 31 days of its due date. For three months, premiums were not received because the funds in Thomas’s bank account were too low.

After several letters from Fidelity warning of lapse, a notice of lapse was mailed to Cook, stating that the policy had lapsed in November 2010. An application for reinstatement was enclosed. In December 2010, Fidelity informed Cook that the reinstatement process was closed because no application (or the missing payments) had been received.

In February 2011, Thomas and her insurance broker had a telephone conversation with an unidentified agent of

Fidelity who, according to Thomas, stated that the policy would not lapse if Thomas paid the January and February premiums, along with a six-month advance payment, by the end of March. The agent also advised Thomas to send in the reinstatement application in case her premium check did not arrive by the end of March.

In mid-March, Thomas forwarded the premium payments, plus a completed reinstatement application which denied any diagnosis of cancer in the last five years. Fidelity reinstated the policy. In fact, the reinstatement application contained a misrepresentation because Cook had been diagnosed with lung cancer in December 2010. He died shortly after the policy was reinstated.

Fidelity brought an action to rescind the policy after an investigation revealed the

misrepresentation. Thomas argued that the misrepresentation was not material because the policy had never lapsed, based on assurances by the agent which, she said, resulted in a waiver of the right to terminate the policy based on the missed payments.

In that regard, the policy provided: “Only the President, the Secretary, or a Vice President in our Home Office can agree to change or waive any provisions which are part of the entire contract. The change or waiver must be in writing.”

The district court granted summary judgment to Fidelity, concluding that the policy had lapsed and that Thomas had not shown that the Fidelity agent had authority to waive the lapse.

On appeal, the Eleventh Circuit affirmed. In Georgia, the court wrote, “oral statements by an agent of an insurance company generally cannot bind the insurance company.” Moreover, Thomas did not show that the agent was “one of those executives from the home office who had authority to change or waive the terms of the general policy. Nor did she present any evidence that the agent’s offer was reduced to writing.”

As a result, the telephone conversation with the agent did not waive the termination provision of the policy, and Thomas failed to raise a genuine issue as to whether the policy had lapsed.

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Employer Was Not Acting as an ERISA FiduciaryWhen It Accepted Premiums from Plan Participant

Moon v. BWX Technologies, Inc.,2014 WL 2958804 (4th Cir. 2014)

The Fourth Circuit held that an employer was not acting as an ERISA fiduciary when it accepted life insurance premiums from a plan participant without informing him that he no longer was eligible for the coverage. The court concluded that the employer’s actions were not discretionary functions with respect to the management, assets, or administration of the life insurance plan, and that the plan documents did not confer fiduciary status on the employer.

Moon was employed full-time by BWX Technologies and its predecessor corporations from 1969 until 2005. In June 2005, Moon was unable to continue working due to a severe heart condition. He received short-term disability benefits through November 2005. He later applied for long-term disability benefits, and his application was approved in December 2005. As of that date, Moon no longer was employed by BWX.

Sometime during his employment in 2005, Moon enrolled in various employee benefit programs offered by BWX, including a group life insurance policy issued by MetLife providing coverage of $200,000. The MetLife coverage was to become effective January 1, 2006. In a confirmation statement issued in November 2005, several days before Moon went on long-term disability, BWX identified his coverage as “Employee Life Insurance” under the heading “Plan Name.”

In January 2006, BWX printed a second benefit confirmation statement, confirming that Moon had selected certain employee benefits effective in 2006, including a $200,000 life insurance benefit. The 2006 confirmation statement did not indicate that Moon no longer was an employee of BWX.

Moon died in November 2006. The life insurance premium payments were in arrears at the time of his death. Eleven days after Moon’s death, his beneficiary wrote to BWX enclosing a check in payment of the entire balance due. She then made a claim directly to BWX, requesting payment of the $200,000 life insurance benefit.

BWX denied the claim, stating that under the terms of the plan Moon was no longer eligible for group life insurance coverage when he ceased active employment as a result of permanent disability. Moon could have elected to convert his group life

insurance to an individual policy, in which case he would have been required to pay premiums directly to MetLife, but he did not do so.

The beneficiary alleged that, in reliance on the 2006 confirmation statement, Moon and his family paid life insurance premiums directly to BWX, and that BWX accepted the payments without objection. According to the complaint, Moon “reasonably believed that BWX would provide the benefits including life insurance benefits” if he paid the premiums to BWX.

BWX moved to dismiss the plaintiff ’s equitable estoppel and breach of fiduciary duty claims because it was not acting as a “fiduciary,” as that term is defined in ERISA. The district court agreed, noting that a person is an ERISA fiduciary only to the extent that he exercises discretionary authority over the plan. Moon v. BXW Techs., Inc., 956 F. Supp. 2d 711, 717 (W.D. Va. 2013).

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continued from page 5 >> Pulmonary Irritants Unique to Employee’s Work SiteDid Not Support Disability from Her OccupationKennedy v. United of Omaha Life Ins. Co.556 F. App’x 893 (11th Cir. Feb. 28, 2014)

Kennedy sued United of Omaha to recover long-term disability benefits under an ERISA plan, based on an allegedly debilitating pulmonary condition. United of Omaha denied the claim after reviewing the opinions of Kennedy’s pulmonologist, her primary care physician, and an independent pulmonologist who reviewed her medical records.

The federal district court held that the claim decision was not arbitrary and capricious, having taken into account any conflicts of interest. Kennedy appealed, and the Eleventh Circuit affirmed the district court, noting that Kennedy’s pulmonologist had concluded that she was capable of working in her regular occupation if she was not exposed to respiratory irritants.

“Kennedy had not pointed to any evidence in the administrative record demonstrating that the workplace irritants

she encountered at River Point were universal and unavoidable, as opposed to being unique to her specific employer and office space,” the court said. “Accordingly, there was a reasonable basis for United to conclude that Kennedy could work in her regular occupation when, as dictated by the Policy, it set aside peculiarities of Kennedy’s work at River Point and instead considered her occupation generally.”

Although Kennedy emphasized that United of Omaha operated under a conflict of interest, the court said that this was only one factor for the district court to consider in reviewing the claim decision. “The fact that United awarded Kennedy long-term disability benefits pending its investigation, which it did not later seek to recover, is evidence that it rendered an impartial decision despite its conflicts,” the court said.

The district court then concluded that the alleged wrongdoing by BWX did not involve discretionary acts. Therefore, the district court held that the plaintiff ’s equitable estoppel and breach of fiduciary duty claims failed, because BWX was not acting as an ERISA fiduciary at the time of the alleged wrongful conduct.

In affirming, the Fourth Circuit wrote that “[t]o state a claim for breach of fiduciary duty under ERISA, the threshold question is whether the plaintiff has sufficiently alleged that the defendant was a ‘fiduciary,’” as defined by 29 U.S.C. § 1002(21)(A). The Fourth Circuit has observed that an ERISA fiduciary is “any individual who de facto performs specified discretionary functions with respect to the management, assets, or administration of a plan.” Custer v. Sweeney, 89 F.2d 1156, 1161 (4th Cir. 1996). Simply because an employer is an ERISA plan sponsor does not automatically make the employer a plan fiduciary.

Although the plaintiff argued that BWX was a “de facto” ERISA fiduciary, the court held that because the definition of an ERISA fiduciary “is couched in terms of functional control and authority over the plan,” it was required to “examine the conduct at issue when determining whether an individual is an ERISA fiduciary.” BWX’s acceptance of Moon’s premiums during 2006, as well as its failure to notify Moon that he no longer was eligible for life insurance coverage under the MetLife plan, were not discretionary functions with respect to management, assets, or administration of the life insurance plan, but were more akin to the collection of contributions.

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Divorce Decree Must Describe Life Insurance with Sufficient SpecificityUnum Life Ins. Co. of Am. v. Sides, 2014 WL 1207616 (N.D. Ga. Mar. 21, 2014)

Unum Life filed an interpleader action, seeking a judicial determination of the rightful recipient(s) of the death benefit payable under a policy insuring the life of Christopher Sides. Sides had previously been married to Casey Sides, who was the mother of his two minor children. In their divorce settlement agreement, Sides and his former wife each agreed to maintain insurance on his or her life of at least $250,000 with the minor children named as beneficiaries and the other parent named as trustee.

At the time of the divorce, the only life insurance Sides had in place was coverage

under a group policy issued by Unum Life to his employer providing coverage in the amount of his annual earnings, which was far less than $250,000. When Sides later married Brooke Sides, he executed a change of beneficiary form designating her as the beneficiary of his life insurance under the Unum Life policy.

Sides died of cardiac arrest in 2012, and Unum Life filed the interpleader action because both Brooke Sides and Casey Sides (as guardian of the minor children) claimed entitlement to the life insurance proceeds. Casey claimed that the court should impose a constructive trust on

the proceeds because Brooke would be unjustly enriched if allowed to keep the death benefit.

The court disagreed because, although Georgia law supports a vested interest in life insurance when a divorce decree identifies a specific policy, the Unum Life policy was not specifically identified. Thus, Brooke was entitled to the proceeds of the life insurance policy. The court mentioned in dicta that Casey may have a claim against the estate of Sides for his failure to maintain $250,000 in life insurance for his children pursuant to the divorce decree.

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Agent’s Fraudulent Concealment of Terminal IllnessResulted in Rescission of Policy Insuring His BrotherReliaStar Life Ins. Co. v. Laschkewitsch,2014 WL 2211033 (E.D.N.C. May 28, 2014)

Laschkewitsch, an insurance agent, submitted to ReliaStar the application of his brother Ben for life insurance. The policy was issued in February 2010, with Laschkewitsch as the beneficiary. Ben died in January 2012.

ReliaStar denied Laschkewitsch’s claim for the death benefit, based on misrepresentations in the application, and filed a declaratory judgment action. The federal district court declared the policy void and granted summary judgment to ReliaStar on its claims of breach of the producer contract and fraud, ordering Laschkewitsch to repay his commission.

The court found that Laschkewitsch had contrived to acquire $3.9 million in life insurance on the life of his brother, who was terminally ill with ALS. Laschkewitsch helped his brother apply for the policy and made material misrepresentations to ReliaStar about his brother’s health and the amount of life insurance in force or applied for with other companies.

The evidence showed that Ben had been diagnosed with ALS and frontotemporal

dementia in August 2009; in September 2009, Ben disclosed his diagnosis to another insurer, which declined his application for insurance; in October 2009, Ben was terminated from his job because of his inability to perform as a result of ALS; and in January 2010, VA records showed that Ben’s health had declined significantly.

Despite this, Ben answered “no” to questions on the application, including, “[h]ave you within the last 5 years had any mental or physical disorder....?” Ben also misrepresented the total amount of life insurance in force, and that he had been denied coverage by another insurer. ReliaStar showed that it would not have issued the policy if Ben had disclosed his illness, his other coverage, and his pending life insurance application to another company.

The court rejected Laschkewitsch’s argument that ReliaStar waived its objections to the application deficiencies, because waiver requires “knowledge” of false facts and “conduct inconsistent with an intent to enforce the condition.” While an insurer is under no duty to question

the truth of an applicant’s statements, it may learn of facts “sufficient to put it on inquiry,” requiring an “investigation to determine the truth or falsity thereof.” ReliaStar, on several occasions, was placed on inquiry notice of fraud, but each time Laschkewitsch sufficiently covered his tracks to stop the inquiry. The court said that ReliaStar was under “no obligation to dig deeper in order to avoid waiver.”

Next, Laschkewitsch argued that the policy was not contestable. The policy stated: “After your policy has been in force during the lifetime of the Insured for two years from the Issue Date, we will not contest its validity….” Laschkewitsch argued that ReliaStar’s suit could not be maintained more than two years after the policy was issued. The court rejected this argument because the “policy was not in force for two years during the lifetime of the insured.”

Laschkewitsch also argued that ReliaStar was unjustly enriched by receiving premiums and then refusing to pay the claim. The court rejected this argument because all premiums were reimbursed. Finally, Laschkewitsch argued that ReliaStar was estopped from challenging the policy because it retained premiums after Ben died. However, like the unjust enrichment argument, the evidence showed that all premiums were reimbursed.

In ruling on ReliaStar’s breach of contract and fraud claims, the court found that Laschkewitsch breached his producer contract by not disclosing facts that were pertinent to Ben’s insurability. As to the fraud claim, the court found that Laschkewitsch had actual awareness of Ben’s ALS, and thus he made material and intentional misrepresentations on which ReliaStar relied.

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Benefits Decision Was Not Arbitrary Because It Was Supported By Evidence Inconsistent With Insured’s ClaimHoward v. Hartford Life & Accident Ins. Co., 563 F. App’x 658 (11th Cir. 2014)

Howard sued Hartford to recover additional long-term disability benefits, based on subjective diagnoses of lupus and fibromyalgia, among other ailments. The district court granted summary judgment to Hartford, and the Eleventh Circuit affirmed.

Hartford initially approved benefits based on a treating physician’s report that Howard could not perform her occupation as a business strategy manager. To further assess Howard’s capabilities, Hartford obtained surveillance, which showed Howard engaging in activities that were starkly inconsistent with her self-reports and those of her treating physicians.

Hartford consulted an independent physician and an independent psychologist, and both opined that Howard should be able to perform her occupation full-time. Hartford terminated benefits.

On appeal, Howard complained that Hartford’s conflict of interest affected its benefits determination, and that the district court erred in failing to consider extra-record exhibits attached to her summary judgment motion (some of which did not even exist when Hartford made its decision).

The Eleventh Circuit confirmed that it is the claimant’s burden to prove disability, to prove an abuse of discretion by the claim administrator, and to prove that

the decision was affected by the conflict of interest. Because Howard’s allegedly disabling conditions were subjective (i.e., fibromyalgia and a lupus diagnosis without corroborating labwork), the

Eleventh Circuit found that “credibility in this case is of the utmost importance.” Howard’s credibility was “seriously called into question by the surveillance which show[ed] her engaging in activities grossly inconsistent with her description of her abilities, and in stark contrast to her own treating physicians’ assessments” based on her “subjective complaints.”

The court reiterated that a review of a claimant’s records by an independent consultant is not arbitrary and capricious.

Moreover, despite submitting 30 extra-record exhibits with her summary judgment motion, “Howard failed to submit evidence showing the reviewing health care providers were tainted or biased,” such

that “Hartford’s reliance on their opinions was not arbitrary or capricious.” With conflict being just one factor to consider, “the district judge appropriately deferred to Hartford’s decision regarding benefits ....”

It was not necessary for the court to resolve whether the district “erred in failing to consider” Howard’s various exhibits, because the judge “did examine all exhibits Howard tendered but concluded these exhibits did not justify another result.”

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State Law Claims of Breach of Contract and FraudDismissed Because Completely Preempted by ERISADye v. Hartford Life & Acc. Co.,2014 WL 1379246 (M.D. Ga. Apr. 8, 2014)

Dye sued Hartford to recover benefits under a long-term disability insurance policy issued to her former employer, where she worked as a registered nurse. Hartford was the claims administrator of the policy. Dye alleged breach of contract and fraud based on Hartford’s termination of her long-term disability benefits. She also alleged that Hartford acted in “bad faith,” which entitled her to additional damages. Hartford removed the case to federal court, and moved to dismiss the complaint pursuant to Fed. R. Civ. P. 12(b)(6) on the ground that it alleged only state law claims that were completely preempted by ERISA.

The court first considered whether it had subject matter jurisdiction, since complete preemption would confer jurisdiction, in contrast to conflict or defensive preemption, which is an affirmative defense arising from ERISA’s express preemption provision, but which does not provide a basis for removal.

To determine whether complete preemption existed, the court considered (1) whether Dye could have brought her claim under § 502(a) of ERISA, and (2) whether no other legal duty supported the claim. For the first factor, a plaintiff ’s claim must fall within the scope of ERISA, and the plaintiff must have standing to sue under ERISA. The court concluded that Dye could have brought her claim under § 502(a), because

the plan was an employee benefit plan established by her employer, which was an ERISA entity that “controls the payment of benefits and the determination of rights under an ERISA plan.” And, as an employee potentially eligible to receive benefits under the plan, plaintiff had standing to assert this claim. Regarding the second factor, the court noted that Dye’s breach of contract claim, based on her contention that Hartford erroneously concluded she no longer was disabled, necessarily required inquiry into the content of the ERISA plan. Thus, it was not premised on legal duties independent of the plan. Accordingly, plaintiff ’s breach of

contract claim was completely preempted by ERISA, and because the state law fraud and bad faith claims were joined with the completely preempted claim, the court had jurisdiction. With respect to Hartford’s motion to dismiss the state law claims, the court determined that the breach of contract claim necessarily “relate[d] to” an ERISA plan and thus was also defensively preempted. Because the fraud and bad faith claims were “intertwined with the Defendant’s denial of benefits under an ERISA plan,” they too were defensively preempted. Dye’s claims were dismissed.

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Smith Moore Leatherwood LLP | Attorneys at Law | 11

Message from the Editors

Contributors to this Issue

Sanders Carter Kent Coppage Aaron Pohlmann

Among the contributors to this issue is Jenny Rathman, who has represented life, health, and disability insurers for 11 years, first in Chicago and currently in Atlanta and throughout the Southeastern United States. Jenny recently spoke on new legislation affecting fraternal benefit societies at the annual meeting of the Association of Fraternal Benefit Counsel in Santa Fe, New Mexico.

Nikole Crow Atlanta, Ga

Jennifer RathmanAtlanta, Ga

Mary RamsayCharleston, SC

Former Employee Had Right as ERISA Plan “Participant” to Request Copy of SPDEnsley v. North Georgia Mountain Crisis Network, Inc., 2014 WL 1053590 (N.D. Ga. Mar. 19, 2014)

Ensley filed suit under a number of theories after her employment was terminated by the defendant. Among other things, she contended that the administrator of her former employer’s health benefit plan had violated ERISA by failing to timely provide to her a copy of a summary plan description. She contended that she was entitled to administrative penalties as a result.

Under 29 U.S.C. § 1024(b), a plan administrator must provide plan participants with a copy of the SPD upon written request. ERISA defines the term “participant” in relevant part as “any employee ... who is or may become eligible to receive a benefit of any type from an employee benefit plan which covers employees of such employer ... , or whose beneficiaries may be eligible to receive any such benefit.” 29 U.S.C. § 1002(7).

The defendants admitted that Ensley was not provided with a copy of the SPD within the timeframe set out in the statute. Nonetheless, they argued that she was not entitled to an SPD because her written request for the document was made after the termination of her employment when she was no longer a plan “participant” within the meaning of ERISA.

The court rejected the defendants’ argument, noting that in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 117-18 (1989), the Supreme Court “found that ‘participants’ include former employees who have a reasonable expectation of returning to covered employment or a colorable claim to vested benefits.” Under that decision, the court continued, “the former-employee claimant ‘must have a colorable claim that (1) he or she will prevail in a suit for benefits, or that (2)

eligibility requirements will be fulfilled in the future.’”

The court agreed that Ensley had “at least a colorable claim to benefits.” As a result, the court concluded, the plan administrator “did have an obligation to provide her with plan information following her attorney’s written request ....” The court reserved ruling on awarding statutory penalties until overall damages had been addressed.

Peter RutledgeGreenville, SC

Page 12: ERISA and Life Insurance News

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