The Employee Retirement Income Security Act of 1974, also know as ERISA, was enacted by Congress to protect the welfare and retirement benefits of employees. Over the years, its many provisions have been the subject of thousands of lawsuits; each of which seems to have left the ERISA landscape even more confusing. This article will discuss two sections of ERISA that led to different results in two recent cases.
The first section that we will discuss is 29 U.S.C. section 1102(a)(1), which provides that an ERISA plan must be in writing.
Every employee benefit plan shall be established and maintained pursuant to a written instrument.
And, as case law has developed, it has become clear that the plan must be operated in accordance with its written plan document.
The second section is 29 U.S.C. section 1133, which provides that a participant must be given written notice of the denial of a claim and an opportunity to appeal the denial of the claim.
In accordance with regulations of the Secretary, every employee benefit plan shall –
(1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and
(2) afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.
In Yates v Symetra Life Insurance Company, decided by the United States Court of Appeals for the Eighth Circuit on February 23, 2023, the Court found that the plaintiff, Yates, was entitled to benefits under her employer’s welfare benefit plan.
Yates was a participant in her employer’s welfare benefit plan. Her husband was also a participant as her dependent. The plan was administered by Symetra and funded by insurance contracts issued by Symetra. One of the plan’s benefits was accidental death and dismemberment, which paid a benefit if a participant “suffered . . . loss of life . . due to accidental bodily injury”. The insurance policy also contained certain exclusions, one of which denied coverage for “any loss caused wholly or partly, directly or indirectly by . . . intentionally self-inflicted injury while sane”.
When Yates’ husband died of a heroin overdose, she filed a claim with Symetra under the accidental death and dismemberment policy. Symetra denied the claim, and, in its denial letter, outlined, in detail, the plan’s appeal process. That process afforded a participant the right to file a request for review within 60 days of receipt of written notice of the denial of the claim. The letter also advised Yates that she had the right to bring a civil lawsuit against the plan if the appeal process did not result in the granting of her claim.
Yates, however, did not file an appeal with the plan administrator. She, instead, went directly to filing a lawsuit against Symetra under 29. U.S.C. section 1132(a)(1)(B), which provides that:
A civil action may be brought—
(1) by a participant or beneficiary—
(B) to recover benefits due to him under the terms of his plan . . .
Symetra filed an answer to the complaint and eventually moved for summary judgment on two grounds, one procedural and one substantive. First, Symetra claimed that Yates could not bring a lawsuit because she had not followed the plan’s appeal process. Second, Symetra claimed that she was not entitled to benefits because her husband’s death was not accidental. It was the result of his intentional use of heroin. Therefore, his death was self-inflicted.
As noted above, ERISA requires that an employee benefit plan be in writing and that it provide an appeals process when a claim for benefits is denied. However, no provision of ERISA actually requires a participant to engage in the appeals process before filing a lawsuit against the plan. That is a rule that has developed through case law and is sometimes referred to as the “exhaustion of administrative remedies” rule.
In the instant case, the plan documents did not contain a review process. That process was outlined in the denial letter sent to Yates by Symetra. Symetra claimed that the process outlined in the denial letter imposed on obligation on Yates to exhaust her administrative remedies, even if the plan did not contain such a provision. The Court disagreed with Symetra. It ruled that it would not impose a requirement on a participant to exhaust her administrative remedies when the written plan document did not provide an administrative remedy.
A participant in an employee benefit plan governed by ERISA is not required to exhaust administrative remedies before challenging a denial of benefits in court when the written plan documents make no mention of any review process or administrative remedies that can be exhausted.
Once the Court dispatched Symetra’s procedural argument, it then considered its substantive argument. The Court noted that the loss at issue was the death of Yates’ husband. The cause of his death was a heroin overdose. The question, therefore, was whether the overdose was “intentionally self-inflicted”.
In a result that might seem counterintuitive, the Court held that his death was not the result of an intentionally self-inflicted injury. While he intended to use heroin, he did not intend for his use to result in an overdose that would cause his death. Therefore, Yates’ claim was not precluded by an exclusion under the policy, and she was entitled to benefits under the plan.
The plain language of Symetra’s “intentionally self-inflicted injury” exclusion does not apply to unintended injuries like Yates’s husband’s heroin overdose. See King, 414 F.3d at 1004; see also Kitterman, 632 F.3d at 448 (“Our task is to ‘interpret the terms of the plan by giving the language its common and ordinary meaning . . . .’” (quoting Adams, 364 F.3d at 954)). Thus, Symetra’s denial of Yates’s claim for accidental death benefits based on that exclusion was erroneous, and the district court properly concluded the same.
The case, Hayes v Prudential Insurance Company of America, decided on February 23, 2023, by the United States Court of Appeals for the Fourth Circuit, also involved a written plan document. But, in this case, the Court found that the plan document precluded coverage.
Hayes’ husband was a participant in his employer’s death benefit plan. The plan was funded by a group-term life insurance contract issued by the defendant, Prudential. When his employment ended, his coverage under the Prudential policy also ended. However, every group-term life insurance contract contains what is known as a conversion right. It gives an employee, whose group-term coverage has terminated, the right to convert that coverage to an individual policy. The Prudential policy required terminated employees to exercise their conversation right within 31 days of the termination of their group coverage.
Unfortunately, Hayes’ husband did not attempt to exercise his conversion right until 26 days after the expiration of the 31-day conversion period. He died soon thereafter. When Hayes filed a claim with Prudential, her claim was denied because her husband was not covered under a Prudential policy at the time of his death. Hayes filed an appeal with Prudential in accordance with the process outlined in the plan documents. When her appeal was denied, she filed this lawsuit.
This was an easy case for the Court to decide. The plan documents required an employee to exercise his conversion rights within 31 days of the termination of his group coverage. Hayes’ husband did not. As a result, she was not entitled to benefits.
Employers have large leeway to design [employee benefit] plans as they see fit,” but “once a plan `is established, the administrator’s duty is to see that the plan is maintained pursuant to that written instrument.” Heimeshoff, 571 U.S. at 108 (alterations and quotation marks omitted). Prudential did not abuse its discretion by fulfilling its duty here, and the district court correctly resolved the single claim before it based on the agreed-on facts and consistent with well-established law. The judgment of the district court is thus AFFIRMED.
ERISA plans are governed by their written plan documents. It is vital that every employee read and understand their employer’s plan documents so they know what is and is not covered, as well as the steps they must take in order to claim benefits.