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New Ninth Circuit Case Limits Standing of ERISA “Plan Beneficiaries” to Exclude Healthcare Providers

The McKennon Law Group PC periodically publishes articles on its Insurance Litigation and Disability Insurance News blogs that deal with frequently asked questions in insurance bad faith, life insurance, long term disability insurance, annuities, accidental death insurance, ERISA and other areas of law. To speak with a highly skilled Los Angeles long-term disability insurance lawyer at the McKennon Law Group PC, call (949)387-9595 for a free consultation or go to our website at mslawllp.com and complete our free consultation form today.

Who can sue under the Employment Retirement Income Security Act, otherwise known as “ERISA?” This continues to be a contested question under ERISA and cases are still grappling with this issue. Typically, only certain individuals and entities may bring an action to enforce ERISA protections. As frequently discussed on this blog, ERISA provides procedural and fiduciary protections that govern employer-sponsored health insurance, disability insurance, life insurance and retirement plans. However, if you want to sue under ERISA, you first must qualify for its protection as a plan “participant” or “beneficiary,” as defined in the relevant provisions of ERISA. See ERISA § 502(a), 29 U.S.C. § 1132. On March 22, 2017, the Ninth Circuit narrowed the term ERISA plan “beneficiaries” to exclude healthcare providers, eliminating their right to sue under ERISA in most situations. See DB Healthcare, LLC v. Blue Cross Blue Shield of Ariz., Inc., No. 14-16518 (9th Cir. March 22, 2017).

This article details the facts and holding of DB Healthcare, and the potential impact it may have on plan participants and beneficiaries, including individuals insured under ERISA-governed employment insurance plans. First, we provide a brief background on ERISA’s definition of an employment plan “participant” and “beneficiary” and why that is an important matter in ERISA litigation. Next, we briefly discuss the case before the Ninth Circuit, including the details of its decision, the factual history, the Ninth Circuit’s rationale and its ultimate ruling. Finally, we briefly discuss the potential impact that this case may have on healthcare providers, as well as other potential avenues for recovery under state law.

Who is an ERISA Plan “Participant” or “Beneficiary”?

As noted above, and in several of our other blog articles on this topic, ERISA provides foundational procedural and fiduciary protections for individuals insured under employer-sponsored health, disability and retirement plans. However, not all employer-sponsored insurance plans are subject to ERISA and not all individuals have the right to sue under ERISA. This is true even if the plan is considered an “ERISA” plan, i.e., the health insurance, disability insurance or retirement plan is sponsored by a nongovernment employer.

ERISA outlines who can sue to vindicate a claim under ERISA as “participants” and “beneficiaries” under section 502(a). ERISA defines “beneficiary” as “a person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit thereunder.” 29 U.S.C. § 1002(8). However, as the Ninth Circuit noted in DB Healthcare, ERISA does little to define “benefit.” But, given the use of benefit in other contexts in ERISA, the courts have determined “benefit” to include only services received by plan participants and beneficiaries, and not the cost of those services provided by medical providers. The term “benefit” refers to the specific advantages provided to covered employees, as a consequence of their employment, for particular purposes connected to alleviating various life contingencies.

DB Healthcare, LLC v. Blue Cross Blue Shield of Ariz., Inc.

In DB Healthcare, the Ninth Circuit decided two similar cases together, as both addressed the same central issue: whether a healthcare provider (the doctor or hospital that provides healthcare) designated to receive direct payment from a health plan administrator for medical services is authorized to sue under ERISA. Ultimately, the Ninth Circuit answered “no” under two separate bases for such authority under ERISA: direct statutory authority and derivative statutory authority through assignment.

The Plaintiffs in DB Healthcare included twelve medical facilities in Arizona, ten nurse practitioner employees and a medical facility in Bakersfield, California (collectively “Healthcare Providers”). The defendants, the administrators for the relevant ERISA governed employee benefit plans, were Blue Cross Blue Shield of Arizona, Inc. and Anthem Blue Cross Life and Health Insurance Company (collectively “ERISA Plan Administrators”). The two parties were engaged in a reimbursement dispute from 2010 and 2011. The Healthcare Providers performed blood tests and other services for the individual patients subscribed to an employer-sponsored plan. Initially, the ERISA Plan Administrators reimbursed the Healthcare Providers, but later changed course and decided the Healthcare Providers were not actually entitled to reimbursement and demanded repayments totaling $270,00 and $295,912.87. The Healthcare Providers refused to return the money and the legal battle in DB Healthcare ensued. In general, the Healthcare Providers alleged that the ERISA Plan Administrators violated ERISA’s protections when they unilaterally determined that the blood tests and other services performed were not reimbursable. The Healthcare Providers then filed lawsuits against the ERISA Plan Administrators. The Healthcare Providers alleged two claims under ERISA in their complaint. First, they sought injunctive relief regarding Blue Cross’s refusal to credential nurse-practitioners and its threat to cancel provider agreements, alleging that Blue Cross violated ERISA’s prohibition against retaliation for the exercise of rights guaranteed by employee benefit plans. See 29 U.S.C. § 1140. Second, they sought a declaratory judgment that Blue Cross’s recoupment efforts violate the ERISA Claims Procedure, 29 U.S.C. § 1133, and the ERISA Claims Procedure regulation, 29 C.F.R. § 2560.503-1, which provide procedural protections for ERISA claimants.

The Ninth Circuit affirmed the district court judgments dismissing the actions.

First, consistent with several other circuits, the Ninth Circuit found that the Healthcare Providers were not “beneficiaries” within the meaning of ERISA’s enforcement provisions and could not bring claims directly under ERISA. The Court’s rationale was that reimbursement for healthcare services is not a “benefit” within the meaning of the ERISA. Given that ERISA’s definition of “beneficiary” is based on whether the person is entitled to receive benefits, Healthcare Providers cannot be deemed a beneficiary under ERISA because they are only entitled to reimbursement and not the actual medical, surgical or other “benefits” provided.

Second, the Ninth Circuit held that the Healthcare Providers could not bring their claims under derivative authority, through assignment by individual employee beneficiaries. In determining that the Healthcare Providers were not entitled to reimbursement, the Ninth Circuit reviewed the several contracts that governed the relationships between the parties. The Court took specific note of the non-assignment clauses in the governing employee benefit plans.

As a general matter, such “non-assignment” clauses prohibit the insured individuals from assigning any of their rights under the plan to third parties. For example, the non-assignment clause from DB Healthcare read as follows: “The benefits contained in this plan, and any right to reimbursement or payment arising out of such benefits, are not assignable or transferable, in whole or in part, in any manner or to any extent, to any person or entity. . . .” What this means is that the “benefits” of the insurance policy protections extend only to the individual employee and he cannot transfer that right to someone else. Thus, although the patients signed forms to the Healthcare Provider that stated “I Hereby Authorize My Insurance Benefits to Be Paid Directly to the Physician,” the court held that those forms did not actually give the Healthcare Providers the right to reimbursement because the assignment language referred only to direct payment of insurance benefits to the Healthcare Providers, with no reference to broader rights. The rights to declaratory and injunctive relief or to sue for breach of fiduciary duty were not within the scope of the assignment.

What does this mean moving forward?

While this case limits the possibilities for reimbursement for some healthcare providers, it does not entirely foreclose recovery. There is no reason that the Healthcare Providers in DB Healthcare could not have brought their claims in state court as ERISA would not have preempted them. See Blue Cross of Cal. v. Anesthesia Care Ass’n,, 187 F.3d 1045, 1050–52 (9th Cir. 1999). Moreover, if medical providers cannot sue under ERISA because of an existing anti-assignment clause in the ERISA plan document, it is possible that they may still be able to bring an action against a claims or plan administrator for breach of oral contract, equitable or promissory estoppel and other theories for recovery under state law if the claims or plan administrator pre-authorized coverage of the claim directly with the medical provider. See Morris B. Silver M.D., Inc., v. Int’l Longshore & Warehouse Union Pac. Maritime Ass’n Welfare Plan, 2 Cal.App.5th 793 (2016) (holding that ERISA did not preempt provider’s claims for breach of oral contract, quantum meruit and promissory estoppel).

Having an experienced disability, health and life insurance attorney matters to the success of your insurance matter, particularly when complicated issues like the above apply to your claim. If your claim for health, life, short-term disability or long-term disability insurance has been denied, you can call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA insurance claims.

McKennon Law Group PC Voted Top California Insurance Litigation Law Firm for 2017

McKennon Law Group PC is proud to announce it was votedas Corporate LiveWire’s Global Awards 2017 “Insurance Litigation Law Firm of the Year – California, USA.”Corporate LiveWire Global Awards are awarded to the most successful individuals, companies and organizations in the Americas, Europe, Asia & Australasia, Africa & the Middle East, over the past year. Award categories include a wide variety of specialist fields including insurance law, intellectual property, company formations and family law. The Global Awards honor those who stand out for consistently showing best practice in every aspect of their work and who have excelled within their practice areas.

Disability Insurers Cannot Use Ambiguities in Insurance Policies to Avoid Being Sued When They Wrongfully Deny Disability Benefit Claims

When terms contained within an insurance policy fail to make provisions clear, plain, and conspicuous, insureds are often left to wonder what their rights under an insurance policy are and whether they are complying with the terms of their policy. The Ninth Circuit Court of Appeals has long recognized that in cases governed by ERISA, “ambiguities in insurance contracts must be construed against the insurer.” McClure v. Life Ins. Co. of North America, 84 F.3d 1129, 1134 (9th Cir. 1996). Despite this long-standing and binding rule, long-term disability insurance policies issued by disability insurance companies continue to contain ambiguous provisions and insurers continue to use these ambiguities to their advantage and deny valid claims for disability benefits.

Recently, the Northern District of California refused to accept a disability insurer’s argument that the insured’s disability claim was barred by a limitation contained in the long-term disability insurance policy, stating that legal action must be brought within three years from the time proof of claim is filed. Nancy Hart v. Unum Life Ins. Co. of America, No. 15-cv-5392-THE, 2017 WL 565026 (N.D. CA. Feb. 13, 2017). The long-term disability policy at issue in Hart contained a provision stating that a legal action can be brought “up to three years from the time proof of claim is required.” Unum sent Ms. Hart a letter terminating her claim for long-term disability benefits, indicating that she had 45 days to provide proof of continuing disability and 180 days to appeal the denial decision. Unum argued that the three year contractual limitation in Ms. Hart’s policy was triggered when the 45-day deadline to provide “proof of continuing disability” expired, as the term is interchangeable for the term “proof of claim.” Under this argument, Ms. Hart’s lawsuit against Unum would have been barred by the limitation within the Policy. Ms. Hart argued that the policy limitation was not triggered until the 180 day deadline to appeal the denial of her claim expired, and therefore her complaint was timely.

The District Court determined that the long-term disability plan failed to clearly demonstrate that there was no distinction between the terms “proof of claim” and “proof of continuing disability.” The Court noted that even though both terms were found within the same section of the Policy, Unum failed to make it “clear, plain, and conspicuous” that in applying the contractual limitation there is no distinction between the two terms. Because of this, the Court found that the termination letter did not trigger the three-year contractual limitation to file a lawsuit by asking Ms. Hart to provide proof of continuing disability within 45 days.

The Court went on to determine that even if “proof of claim” and “proof of continuing disability” were interchangeable, Ms. Hart is not barred from filing her lawsuit because the letter’s inclusion of two different deadlines, the 45-day deadline to provide proof of continuing disability and the 180-day deadline to appeal the letter’s decision, created an ambiguity that must be interpreted in favor of the insured. The Court observed that the Ninth Circuit has held that an insurer must utilize language from its own policy to inform an insured when the contractual time limitation for legal proceedings would begin to run, and ambiguities would be construed against the insurer. The Court concluded that the insurer “should not be allowed to take advantage of the very ambiguities that it could have prevented with greater diligence,” and the Court denied Unum’s motion for summary judgment determining that Ms. Hart’s lawsuit was filed timely because it was filed within 3 years from the 180 day deadline to appeal Unum’s denial decision.

When a claim for disability benefits is denied, insureds can often feel overwhelmed by the confusing provisions contained in their policies and they can also feel obligated to accept the denial justifications provided by their insurers. However, it is important to understand that insurers will often interpret policy provisions in their favor in order to justify a denial of a claim, even if the provision is unclear or could be subject to multiple interpretations. The Hart decision illustrates why it is important to have experienced disability, health and life insurance attorneys like the attorneys at McKennon Law Group, PC on your side when your claim for insurance benefits has been denied. If your claim for insurance benefits has been denied, you can call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA insurance claims.

When Does ERISA Apply to a “Continued” or “Converted” Group Insurance Policy?

Do you have an employer-sponsored group long-term disability insurance policy, a group life insurance policy or a group medical insurance policy? What do you do when your employer-sponsored group plan is terminated and you have the option to continue or convert the policy? Should you choose to continue or convert your life, health or disability insurance plan, what law governs any claims you make under the new policy? As we have discussed in previous articles on this blog in depth, the Employment Retirement Income Security Act of 1974, otherwise known as ERISA, governs most employer-sponsored benefit plans, including long term disability insurance, life insurance, health insurance and retirement plans. ERISA was enacted to protect employees from abuse of those employer-sponsored benefits plans and requires that the plan and claim administrators, usually the employer and the insurance company, adhere to strict fiduciary standards when resolving disputes that fall under ERISA. However, not all insurance policies fall under ERISA, even if the policy was originally part of an employer-sponsored plan.

In this article, we address the first step in assessing an insurance claim that may or may not be governed by ERISA, with a focus on whether ERISA applies to your continued or converted long term disability insurance, life insurance or health insurance policy. In general, for ERISA to apply, the employer-sponsored plan must meet certain requirements and must not be established or maintained by a church or government entity. However, sometimes ERISA may apply to a policy that is no longer sponsored by your employer, which may depend on whether the policy is considered a “continued” or a “converted” policy. This article discusses this nuance in depth, first outlining the difference between a “continued” and a “converted” insurance policy and then discussing when ERISA may apply to each.

What is a “Continued” Insurance Policy and When does ERISA Apply?

A “continued” insurance policy arises where the terms and conditions of the group policy allow the employee an option to continue the policy, exactly as it is, for a certain period of time regardless of separation from the employer that originally provided the plan. Because a continued policy remains the same as the original employer-sponsored policy, ERISA typically continues to govern those claims. For example, in Alexander v. Provident Life & Acc. Ins. Co., 663 F.Supp.2d 627 (E.D. Tenn. 2009), the plaintiff’s employer sponsored a disability insurance policy. Plaintiff’s employment terminated, but the policy had a provision that allowed for continued coverage within a certain period of time, regardless of employment. Specifically, the provision stated that it was “non-cancellable and guaranteed continuable at guaranteed premiums to [the policyholder’s] 65^th birthday, or five years, whichever is later.” Under the terms of this policy, the plaintiff was free to continue the policy at the guaranteed premiums, regardless of whether he was still employed by the employer that brokered the original deal to get that policy. In this case, the plaintiff elected to continue coverage under the same policy number and under express language that the policy “continued.” In this case, the court found that ERISA still governed this policy because the same considerations existed under ERISA and there was no change in the terms or conditions of the policy, as it just “continued” from the original employer-sponsored plan.

What is a “Converted” Policy and When does ERISA Apply?

In contrast, a “converted” policy is one where the right to convert from a group policy to an individual policy typically arises after the group policy has terminated and the group policy provides for a right of conversion. When a plan is considered “converted” the ERISA analysis becomes more difficult than a continued policy. Under a converted policy, if the issue is whether the policyholder has a right to convert the policy and that right is governed by an ERISA plan, then the courts will typically find that ERISA governs that dispute. However, if the policyholder has already exercised his or her individual right to convert the policy, and maintains an otherwise individual plan based on the provision arising in an ERISA policy, the determination becomes more complicated.

In some circuits, because the converted policy arose out of an ERISA governed policy, it is considered indelibly tied to the ERISA governed policy. As such, in those circuits, a policy that arises from a conversion provision in an originally ERISA governed plan will continue to be governed by ERISA. However, in other circuits the term “conversion” is taken in a more literal sense. In those circuits, when a policy converts from a group to an individual policy it is considered entirely converted for the purposes of ERISA. What this means is that once a policy becomes an individual policy no longer governed under the terms of the group-sponsored plan, the plan is no longer governed by the terms of ERISA because it is no longer established or maintained by your employer.

For example, in Arancio v. Prudential Ins. Co. of America, 247 F.Supp.2d 333 (S.D.N.Y. 2002), the Plaintiff Arancio had exercised his right to convert his group disability insurance policy into an individual disability insurance policy. Although the right to convert originated with his former employer, Riverbay, after conversion, Plaintiff Arancio held the policy the same as any other individual. The Policy named Prudential, and not the employer, as the administrator. Further, Riverbay no longer financed the policy and instead Arancio paid the premiums. The court also noted that, under the converted policy, all communication regarding the claim were directly between Plaintiff Arancio and Prudential, without involving Arancio’s former employer. In effect, Plaintiff Arancio converted his formerly group plan into an individual policy directly with Prudential and the court found that, as such, his disability insurance policy had the requisite independent relationship to remove it from ERISA.

Determining whether a converted policy is governed by ERISA can be a complex undertaking and the above are just a few considerations to keep in mind when a continued or converted policy may or may not still be subject to ERISA.

Insurance Company Claim Denials: How Insurers Deny Legitimate Life Insurance Claims

The McKennon Law Group PC periodically publishes articles on its California Insurance Litigation Blog that deal with related issues in a series of articles dealing with insurance bad faith, life insurance, long-term disability and short-term disability insurance, annuities, accidental death insurance, ERISA, and other areas of the law. This is the fourth in a series of articles on How Insurance Companies Deny Claims. To speak with a highly skilled Los Angeles long-term disability insurance lawyer at the McKennon Law Group PC, call (949) 387-9595 for a free consultation or visit our website at www.mckennonlawgroup.com and complete a free consultation form.

Like the U.S. Department of Labor statistics referenced in our earlier articles in this series about the alarming number of denied long-term disability and health insurance claims, there is also empirical evidence that life insurers often do not treat their insureds fairly. Recently, 60 Minutes profiled a national investigation headed by numerous state Insurance Commissioners confirming that life insurers had inconsistently used the Social Security Administration’s Death Master File database to identify deceased annuity holders to stop making annuity payments (to their financial benefit). But they failed to use the database to identify deceased policyholders to pay life insurance benefits (again to their financial benefit). This reportedly deprived life insurance beneficiaries of over $5 billion in benefits nationwide. We blogged about this topic in prior articles. (See https://mslawllp.com/national-investigation-uncovers-systemic-practice-among-life-insurers-depriving-beneficiaries-of-5-billion/). Some life insurers are still refusing to cooperate and use the database to pay life insurance benefits they owe. The lesson is you should not trust your life insurer to grant your claim just because you believe they will do the right thing.

Life Claim Denials

How do insurers deny valid life insurance claims, whether they are governed by federal law, the Employee Retirement Income Security Act (“ERISA”), or California/state insurance bad faith laws? One common way is “rescinding” the policy after learning the policyholder has died and the beneficiary makes a claim. That is, the insurer invalidates or voids the policy – as if it never existed – based upon what is commonly called a “two-year contestability investigation” into the insured’s pre-insurance medical history and insurance application. If the policy is legitimately rescinded, the insurer does not have to pay the death benefit but just return the policy’s premiums.

While that seems unfair to a grieving family who has dutifully paid premiums precisely for such a time as this, there is support for this tactic under most life insurance policies. Fortunately, though, only under very narrow circumstances. Almost every life insurance policy has a two-year incontestability clause. If the policyholder dies within two years of purchasing the policy, the insurer can rescind it if the insured made a material misrepresentation about his health or his activities on his life insurance application. After two years, in most policies, the insurer cannot contest or rescind the policy based on misstatements made in the application, even fraudulent ones. What is a “material” misrepresentation? That means the insurer, had it known the true facts that were omitted from the application, would have been influenced in its decision whether to accept the risk and issue the policy.

We have found that life insurers liberally interpret what is “material” to deny legitimate claims. They will rescind the policy after a claim is made if their contestability investigation shows the insured left out any information about his health or incorrectly answered even an innocuous application question, irrespective of whether having the correct information would have changed the insurer’s mind to not issue the policy. The law does not permit an insurer to do that. If the insurer would have issued the same policy at the same price even if had it known the true facts about the insured’s health condition, the information is not likely considered “material” and the insurer is not allowed to rescind. The Ninth Circuit, agreeing with the California Supreme Court, has stated:

Finally, as the misrepresentation must be a material one, [a]n incorrect answer on an insurance application does not give rise to the defense of fraud where the true facts, if known, would not have made the contract less desirable to the insurer.

Freeman v. Allstate Life Ins. Co., 253 F.3d 533, 536 (9th Cir. 2001) (citing Thompson v. Occidental Life Ins. Co., 9 Cal. 3d 904, 915 (1973)).

Illustrative of this devious practice, one of our clients, a minor child, had his recently deceased father’s life insurance policy rescinded after he submitted a claim because the insurer’s contestability investigation revealed his father did not disclose on his application he had mild kidney disease. The insurer refused to pay the policy’s life insurance benefit and voided the policy despite that the premiums had always been paid. When our firm became involved, we argued that such a condition is not typically considered material to life insurers and we demanded to see the insurer’s underwriting guidelines to prove that they considered the condition to be material. We argued the father’s condition was immaterial, that the insurer would have issued him the same policy had he disclosed his mild kidney disease because it was standard to do so under its underwriting guidelines. The insurer immediately paid the claim, thwarted in its dishonest efforts to refuse payment to a needy and now fatherless child so it could deepen its already deep pockets.

There are many other inappropriate tricks life insurers use to deny valid claims, including:

Enforcement of conditions never previously enforced: Accepting an insured’s premiums without requiring him to submit evidence of good health or alerting him it is needed for the policy to issue, only to enforce the policy’s good health provisions years later to argue the policy was never legally issued (after the insured’s death and a claim is made).
Billing miscues/errors: Where a life insurer has issued multiple policies to the same insured, we have seen insurers manipulate the accounting of premium payments to their advantage to credit all or most of the payments to one of the policies and claim the other policy lapsed for non-payment when it had been paid in-full.
Inappropriate policy lapses: A life insurer sends a bill for the policy premium that the insured is too sick to notice and pay, refuses to send a grace period/lapse notice to the insured and then, after the premium is not paid, improperly lapses the life insurance policy just before the insured dies.

Life insurers often try to cancel or lapse policies for non-payment of premiums without following California’s notice requirements, particularly if they suspect a claim is on the horizon. But a life insurance policy cannot be lapsed without adequate notice to the insured which gives him or her a grace period to pay overdue premiums. In California, a statute enacted in 2013 (California Insurance Code section 10113.71) requires individual and group life insurers to (1) include a 60-day grace period from the premium’s due date, (2) mail written notice of pending lapse and termination for non-payment of premiums at least 30 days before the effective date of termination, and (3) mail the notice by first class United States mail within 30 days after a premium is due and unpaid. The notice is also ineffective if the insurer fails to (1) mail such notice to the named policy owner, (2) mail such notice to a designee named pursuant to Section 10113.71 for an individual life insurance policy, and (3) mail such notice to a known assignee or other person having an interest in the individual life insurance policy. In short, a life insurer must send written notice of potential lapse to the right people, in the proper manner, and allow for the right time periods, or the policy is not lapsed.

These technical requirements have likely frustrated life insurers that underwrite policies in states other than California that have less stringent cancellation requirements. Their claims examiners may not be well versed in this relatively new California law or, worse yet, they may ignore the laws they do not like because their insureds are not educated in them. They may improperly deny a claim based on a purported policy lapse that did not lapse because the insurer never followed California’s special statutory notice requirements.

Our Take

These are just some of the ways life insurers find ways to deny legitimate claims. If you have a denied life insurance claim, you need an experienced ERISA life or bad faith attorney such as the lawyers at Mckennon Law Group PC. As mentioned in our last article, after litigating hundreds of life, health and disability claims, it is our experience that many insurers do not get serious about paying these types of claims until they perceive a true threat of their insured being represented by highly effective, experienced lawyers, especially where there is “extra-contractual exposure” (i.e., damages beyond the policy’s benefits such as emotional distress damages, attorney’s fees and punitive damages). You cannot count on your insurer to act in good faith or do the right thing. The Department of Labor statistics and other empirical data show that often they will not pay a claim unless credibly threatened by an insured with a highly effective and experienced lawyer. Let us try to get your insurer to listen.

The California Insurance and Life, Health, Disability Blog at mslawllp.com/news-blog.

Who Gets the Money? Unintended Beneficiaries in ERISA Governed Life Insurance and Retirement Plans

The McKennon Law Group PC publishes articles on its California Insurance Litigation and Disability News Blogs that cover important issues concerning insurance bad faith, life insurance, long-term disability and short-term disability insurance, annuities, accidental death insurance, ERISA, and other areas of insurance law. To speak with a highly skilled Los Angeles long-term disability insurance lawyer at the McKennon Law Group PC, call (949)387-9595 for a free consultation or visit our website at www.mckennonlawgroup.com and complete a free consultation form.

Beneficiary designations in life insurance plans determine who receives plan benefits following the death of a plan participant. As a plan participant under any such life insurance or under a retirement/pension plan, it is important to understand exactly where the money will go when you pass away. If the retirement or life insurance plan is employer-sponsored, it is likely governed by the Employment Retirement Income Security Act (“ERISA”). Under ERISA governed life insurance and retirement/pension plans, there are some specific things to keep in mind when considering beneficiary designations. This blog article briefly discusses some unexpected situations where beneficiary designations may turn out differently than intended, usually when life-changing circumstances are unaccounted for in the beneficiary designation. Next, we briefly cover some basic best practices in ERISA-specific cases, given the additional requirements on form and timing of beneficiary designations under ERISA.

Life-Changing Circumstances and Unintended Beneficiaries

Unintended beneficiary disputes commonly arise when a life event occurs that is otherwise unaccounted for by the life insurance or retirement plan. This “unintended beneficiary” problem appears in a variety of ways, but is easiest to understand through examples, as provided below.

Divorce

One such instance is when a plan participant designates his or her spouse as the beneficiary, but fails to change that beneficiary designation to reflect a divorce. If the plan participant fails to change the beneficiary designation before death, the ex-spouse may receive the plan benefits as designated even if there is a divorce agreement to the contrary. One can imagine how contentious and complex such disputes may become, particularly when they involve current spouses, ex-spouses, children, parents, full-siblings, half-siblings, stepchildren, etc. If the case is governed by ERISA, the plan document controls and regardless of any private divorce agreement to the contrary, the benefits will go to the designated beneficiary.

Murder?

While this sounds extreme, many states have “slayer statutes” specifically designed to prevent a beneficiary from receiving the benefits of a plan where he or she is guilty of murdering the participant. While this seems like an obvious protection, to the extent that the plan is governed by the federal ERISA statute, it is unclear whether state slayer statutes persist or are otherwise preempted by ERISA. This becomes a particularly thorny issue given the conflicting interests at play. While each state’s slayer statute varies, these variances interfere with the uniformity required in ERISA benefits administration for multi-state employers.

Simultaneous Death

In the instance of a simultaneous death, the problem becomes which estate receives the benefit if both the plan participant and the beneficiary die at the same time. In this example, let’s say a husband and wife are killed simultaneously in a car crash. If the wife is the plan participant for a life insurance plan and she designates her husband as the beneficiary, determining who receives the benefits becomes more difficult. Like with the slayer statutes above, this also depends on state survivorship laws and may trigger additional preemption questions under ERISA.

Best Practices for Participants and Beneficiaries

In some cases, ERISA-specific requirements for beneficiary designations may lead to issues where the plan participant clearly did not intend for some person to receive the benefits under the policy, but they do anyway. Given the benefits at stake, and the large potential for complication, it is key for plan participants to adhere to keep some very basic best practices.

1. Ensure that you are aware of the status of your beneficiary designation

Many plan participants make beneficiary designations when they become plan participants. If any changes or updates do need to occur, they may be so far from the initial designation that the plan participant could have completely forgotten about the life insurance policy and beneficiary designation. However, it is important to be educated and ensure that you have a complete, valid beneficiary designation on file for your life insurance or retirement plan under ERISA. Generally, the beneficiary designation should be with either the plan sponsor or the insurer, so you can ask them for a copy.

2. Ensure that your beneficiary designation is up to date

Knowing the status of your beneficiary designation is important, as is knowing that it is up to date. As made clear in the discussion above, failing to change the beneficiary design

ation following life-changing events like marriage, divorce, or death, may result in an unintended beneficiary receiving benefits that you would rather go to someone else. When the plan document governs, as it does in ERISA cases, keeping the beneficiary designation up to date is vitally important.

3. Make sure you have followed the procedures spelled out in your policy or plan to designate the beneficiary you want to receive your life insurance benefits

In 2009, the Supreme Court directly addressed how ERISA plan administrators determine beneficiaries after someone’s death. In Kennedy v. Plan Adm. For Dupont Sav. And Invest. Plan, 555 U.S. 285 (2009), the deceased failed to change the beneficiary designation forms after the divorce. Although the ex-spouse signed a waiver of rights to the pension during their divorce, the deceased’s estate felt it should pass to the estate whereas the ex-spouse still felt entitled to the interest as the designated beneficiary. The Supreme Court held that the plan administrator should not be required to assess complex, competing claims and should only have to look at the properly designated beneficiary under the Plan.

Having an experienced disability, health and life insurance attorney matters. If your claim for health, life, short-term disability or long-term disability insurance has been denied, you can call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA insurance claims.