Source: https://allottafarley.com/lawyer/blog/page_8/Northwest-OH-Legal-Blog.htm
Timestamp: 2019-04-22 20:47:59+00:00

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The Supreme Court dealt a setback to ERISA health funds in Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan. This case places further limits on ERISA Funds’ ability to recover a subrogation or reimbursement claim under the Employee Retirement Income Security Act of 1974 (ERISA).
This case involved a participant, Robert Montanile, who was covered under an ERISA health insurance plan. He was injured in an automobile accident.
The Montanile case is not unique in its facts as subrogation cases go. Mr. Montanile was seriously injured by an intoxicated driver, sued him for $500,000 and was awarded recovery for the entire amount. The health plan for Mr. Montanile’s union, the National Elevator Industry, had already paid out $120,000 on behalf of Mr. Montanile to cover his medical expenses associated with the accident. Communications between the plan’s board of trustees and Mr. Montanile’s lawyer were disjointed and his attorneys advised the trustees that the entire settlement fund would go to Mr. Montanile unless the trustees objected promptly. The plan’s board of trustees waited 6 months to file an ERISA Section 502(a)(3) action, demanding that the plan be “made whole” for the expenses paid on behalf of Mr. Montanile, that related to the accident for which he received the $500,000 settlement. But Mr. Montanile argued that, during the 6-month lag between his receipt of the settlement and the action filed by the plan’s board of trustees, that he spent all of the money so there were no funds that could be identified to seize.
The plan’s trustees argued that the Supreme Court’s decision in Sereboff v. Mid Atlantic Medical Services, LLC, 547 U.S. 356 (2006) eliminated any need for the plan to trace the recoverable assets. But the Court did not agree, holding that Sereboff does not contain any exceptions to the general asset-tracing requirement for equitable liens by agreement. Instead, the Court went back to a case decided in 2002, Great West Life and Annuity Ins. Co. v. Knudson, 534 U.S. 204 (2002), where it held that the settlement funds must be identifiable and within the possession of the defendants (the plan). It then sent this case back to the U.S. District Court to determine whether any assets from the settlement could in fact, be traced.
Montanile will have the unfortunate effect of increasing litigation between members that incur accidents and their self-funded health insurance plans as well as ERISA-covered disability plans. Plan members will now have an incentive to quickly disburse and spend funds on non-traceable expenditures, such as groceries, utilities, phone bills, gambling debts and other disposable items that are not “traceable” instead of cars, boats, stocks, bonds and other savings alternatives.
So what does the Montanile case mean to Boards of Trustees and plan administrators? For one thing, plan administrators will hesitate to patiently negotiate with a member’s attorney to settle a plan’s reimbursement issues. Instead a law suit will need to be filed at the first notion that a claim cannot be resolved quickly after the settlement or recovery is awarded, to avoid the confusing decision reached by the Supreme Court. Additionally, changes may need to be made to plan documents, summary plan descriptions (SPDs), claims’ notices and subrogation forms to clarify and assert a plan’s right to settlement assets. For Boards of Trustees and plan administrators, these changes will require quick decisions and an extreme drift from the normal status quo in subrogation transactions within employee benefit plans.
The case involves a participant who was enrolled in one of the plan’s self-insured medical options. The claims administrator (an insurance company acting under an administrative services agreement (ASA)) denied his initial claim and appeal. The participant sued. The claims administrator and the employer asked the court to apply the deferential standard of review (under which a court generally upholds a plan’s exercise of duly-authorized discretion, so long as it was not an abuse of discretion).
The court examined a variety of provisions in various documents cited by the employer and the claims administrator before concluding that, even if taken together (adopting the most generous interpretations of several poorly drafted attempts at incorporation by reference), these provisions still did not amount to the requisite grant of discretionary authority. For example, the plan document stated that a claims administrator (for a particular benefit) “may” have authority to exercise discretion in initial claim determinations and “certain” appeals. An SPD included similar language, as well as a reservation of the employer’s “sole authority” to exercise discretion “except to the extent such authority has been delegated.” Finally, the ASA, which the court reasoned might be relevant in interpreting ambiguous plan language, stated that the employer, and not the claims administrator, had “full and final authority” to interpret the plan. Thus, the plan did not contain the unambiguous grant of discretionary authority to the claims administrator required to avoid de novo review. In essence the provisions were too vague.
The case will be heard by the court on the merits and the court will apply its own interpretation of the plan’s terms to determine coverage of the claim without deferring to the interpretation of the plan administrator. Not being entitled to deferential review can have a real impact because the court might interpret terms, such as medical necessity, differently from the claims administrator.
This case highlights the importance of clarity in making, documenting, and adhering to grants of discretionary authority. Some of the ambiguity in this case was due to the patchwork of documentation for the plan’s various benefit options. The procedures and designated persons making decisions for different benefits should be spelled out explicitly.
The elective deferral (contribution) limit for employees who participate in section 401(k), 403(b), most 457 plans, and the federal government’s Thrift Savings Plan remains unchanged from the limit in 2015, $18,000.
The catch-up contribution limit for the above listed plans for employees aged 50 and over also remains unchanged from the limit in 2015, $6,000.
The annual benefit limitation for defined benefit plans under Code Section 415(b)(1)(A) remains unchanged in 2016 at $210,000.
The annual addition limit for defined contribution plans under Code Section 415(c)(1)(A) remains unchanged in 2016 at 53,000.
The following table sets forth the Code limits applicable to 401(k) plans, profit sharing plans, and defined benefit plans for 2016, with a comparison to such limits for 2015 and 2014.
The IRS in Notice 2015-60 announced that the adjusted applicable dollar amount for Patient Centered Outcomes Research Institute (PCORI fees for plan and policy years ending on or after October 1, 2015 and before October 1, 2016 is $2.17.
This is a $.09 increase from the amount in effect for plan and policy years ending on or after October 1, 2014 and before October 1, 2015. PCORI fees are payable by insurers and sponsors of self-insured plans. The fees are calculated by multiplying the applicable dollar amount for the year by the average number of covered lives.
HHS has announced that the form for submitting the 2015 annual enrollment count and remitting the contribution amount owed for the transitional reinsurance program is now available. According to the announcement, contributing entities (generally, health insurers and self-insured group health plans providing major medical coverage) must submit the 2015 form and schedule their reinsurance contribution payments no later than November 16, 2015.
The contribution amount is $44 per covered life. The payment can be paid in a single payment or in two parts. If the contribution is made in a single payment, the payment is due no later than January 15, 2016. If the contribution is paid in two parts, the first payment ($33 per covered life) is due no later than January 15, 2016 and the second payment ($11 per covered life) is due no later than November 15, 2016.
As was the case with the 2014 benefit year, all submissions must be made online through the government portal: pay.gov. A Transitional Reinsurance Contributions webpage (registration required) provides additional information and resources.
PCORI fees are used to fund research on patient-centered outcomes and apply to plan and policy years ending after October 1, 2012 and before October 1, 2019.
Reinsurance contributions are used to fund a temporary reinsurance program (in operation from 2014 through 2016) intended to stabilize premiums in the individual insurance market.
Issuers of specified health insurance policies and plan sponsors of applicable self-insured health plans are responsible for reporting and paying the PCORI fee.
For insured plans, the insurer is responsible for paying PCORI fees and reinsurance contributions. For self-insured plans, PCORI fees are imposed on the plan sponsor and generally cannot be paid from ERISA plan assets. However, the DOL has indicated the board of trustees of a multiemployer plan (which has no other source of funding), as well as a voluntary employees’ beneficiary association (VEBA) providing retiree-only coverage, may use plan assets to pay the fee.
By contrast, Reinsurance contributions are imposed on the plan itself and may be paid from ERISA plan assets.
The Employee Retirement Income Security Act of 1974 (“ERISA”) requires all ERISA-governed plans to notify claimants of their right to bring a civil action in court for the purpose of recovering benefits or enforcing their rights under the plan’s terms. In Mirza v. Insurance Administrator of America, Inc., No. 13-3535 (3d Cir. August 26, 2015), the United States Court of Appeals for the Third Circuit became the latest court to require that ERISA-governed benefit denial letters include specific notice of the plan’s limitations period for bringing a civil action in court. In reaching this conclusion, the Third Circuit joined the First and Sixth Circuits of the United States Court of Appeals. See Moyer v. Metro. Life Ins. Co., 762 F.3d 503 (6th Cir. 2014); Ortega Candelaria v. Orthobiologics LLC, 661 F.3d 675 (1st Cir. 2011).
Background. Under the facts in Mirza, Dr. Neville Mirza performed back surgery on a patient who was a participant in an ERISA-governed healthcare plan sponsored by her employer. Following the surgery, the patient assigned to Dr. Mirza the right to pursue her plan benefits. Dr. Mirza then submitted a claim to the claims administrator, Insurance Administrator of America (“IAA”). IAA denied the claim on the ground that the surgery was medically investigational. Dr. Mirza appealed the decision, but the claims administrator, by letter dated August 12, 2010, upheld IAA’s decision. The letter notified Dr. Mirza of his right to bring a civil action under ERISA Section 502(a)(1)(B), but did not inform him of the plan’s one-year limitation period for bringing suit.
Sometime thereafter, Dr. Mirza and another healthcare provider to whom the participant had assigned her benefit claim rights retained a law firm to pursue their respective claims. On April 11, 2011, 8 months after the plan’s final denial letter, the law firm obtained a copy of the plan document. The plan document required that any lawsuit against the plan or the plan administrator following an adverse benefit determination be filed within one year following receipt of the plan’s final denial letter. Dr. Mirza brought suit on March 8, 2012—almost 19 months after he received the final denial letter.
Despite the plan’s time restriction on civil court actions against the plan or the plan administrator, Dr. Mirza filed a complaint in federal district court, naming IAA as a defendant. IAA moved for summary judgment on Dr. Mirza’s claim, asserting that the statute of limitations had run. The federal district court for the District of New Jersey granted IAA’s motion to dismiss. The district court reasoned that the plan’s one-year deadline for seeking judicial enforcement was reasonable, that Dr. Mirza’s suit was brought after that period had expired, and that he was not entitled to equitable tolling because he had notice (through his attorney) of the deadline.
Ruling on Appeal. Relying on ERISA’s regulatory requirements for benefit denial letters, the United States Court of Appeals for the Third Circuit reversed. The court asserted that the equitable tolling issue was irrelevant and focused only on the defendants’ regulatory obligations under ERISA. United States Department of Labor Regulation Section 2650.503-1(g)(1)(iv), which governs the manner and content of benefit determination notices, requires plan administrators to provide “[a] description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under [ERISA] Section 502(a) following an adverse benefit determination on review.” The court interpreted the word “including” in the ERISA regulation to mean that plan administrators, in their benefit denial letters, must inform claimants of any plan-imposed deadlines for judicial review.
The court observed that this interpretation of the ERISA regulation had been recently adopted by the Courts of Appeal for the First and Sixth Circuits. The court also rejected defendants’ argument that the denial letter to Dr. Mirza substantially complied with the regulations. The court held that the plan administrator’s failure to include the plan’s judicial review time limits in the adverse determination letter caused the letter to fail to be in substantial compliance with the applicable regulatory requirements. The court then concluded that the proper remedy for the defendants’ failure to comply with the regulation was to abrogate the plan’s limitations period and apply the most analogous statutory limitations period under New Jersey state law. In this case, that was New Jersey’s six-year breach-of-contract limitation period. Because Dr. Mirza’s complaint fell within that period, the court remanded the case to the district court for further proceedings.
Takeaways. The Third Circuit’s opinion should alert plan administrators that when they issue benefit denial letters, they should now err on the side of caution by explicitly notifying the recipient of any plan-imposed deadlines for judicial review. As a possible silver lining, the Third Circuit court stopped short of requiring notice of the limitations period for the most analogous state law claim. It noted that, while the issue was not before the court, such a requirement would require legal research into various state laws for each claim and could potentially cause a plan administrator to be perceived as providing legal advice to claimants. Nonetheless, the court’s decision in Mirza should, at the very least, prompt plan administrators to review their procedures for notifying claimants of adverse benefit determinations.
When someone receives an envelope from a court continuing paperwork advising that they have been named in a lawsuit, the usual first reaction is one of panic. That initial reaction is understandable – most people are unfamiliar with how courts operate, and they would rather not be involved in litigation. Fortunately, an experienced attorney can help you navigate through the process.
An attorney can review the documents you received and determine whether the party initiating the lawsuit (called the plaintiff) has asserted claims against you, or whether you have been made part of the proceeding in another capacity. The attorney can also help you determine if any claims against you are covered by insurance, and he or she can help you make a claim with your insurer. If an insurance policy is applicable, the insurance company should appoint a lawyer to represent you in the lawsuit at the insurer’s expense. There are time limits and other requirements that must be met to obtain the benefits an insurance policy provides, so it is important to contact an attorney to look into these matters at the beginning of a lawsuit.
Perhaps the most-important thing to remember when you believe you have been named in a lawsuit is that time is not on your side. There are deadlines that must be met for a variety of actions, and, for example, if you fail to respond to the lawsuit in the applicable time limit, a judgment may be granted against you. As time passes and events occur in the lawsuit without your involvement, it becomes increasingly difficult for any attorney who later becomes involved on your behalf to safeguard your interests. It is therefore critical to contact an attorney as soon as you receive paperwork indicating that you have become involved in a legal process.
On June 30, 2015 the Supreme Court announced that it will review the decision in Friedrichs v. California Teachers Association, a Ninth Circuit Case challenging the constitutionality of charging public sector workers a “fair share fee” when they have opted out of union membership.
When a union is elected as a certified representative for a bargaining unit, they must represent all workers that fall within that classification regardless of their union status. This means that the rights and benefits afforded under the union contract are received by all members of the bargaining unit, not just the union members. It also means that if a non-union member in the bargaining unit faces discipline the union has a duty to represent that individual. Since non-union members do not have to pay union dues, this creates the problem of the “free rider.” A free rider is someone that receives the benefits of union membership (wages, representation, etc.), but does not pay for it.
To eliminate the free-rider problem unions charge non-union bargaining unit members a fair share fee. This fee is calculated as the portion of union dues that the union expends on administering the contract. The fee does not include the portion of dues that Unions spend on political activity or other non-representation matters. This practice by public sector unions, adopted from the private sector, was upheld as constitutional in Abood v. Detroit Board of Education, in 1977. The plaintiffs in Friedrichs object to paying the fair share fee as a violation of their first amendment rights and assert that Aboud was decided wrongly.
Friedrichs follows on a case heard last year, Harris v. Quinn, where the Supreme Court ruled that Chicago home health care providers could that did not want to join a union did not have to pay a fair share fee. Although decided on different grounds, Justice Alito, in his majority opinion, questioned the constitutional foundation that the legality of fair share fees had been based on. Now, with Friedrichs, Alito will have the chance to rule on that very subject.
The importance of Union fair share fees cannot be understated. Without it, the free-rider problem can cripple or even bankrupt a union. For instance, when Indiana eliminated the fair share fee from state law, public sector unions lost 91% of its membership. Likewise, when Wisconsin eliminated the fair share fee AFSCME lost over 50% of its membership. This loss of income used to administer the contract weakens the Unions ability to participate in negotiations, enforce contract provisions, and defend workers that have been wrongfully disciplined by their employers.
Friedrichs represents yet another attack on Unions by the far right. Rather than work with the unions and ensure that all workers receive basic protections and rights, these people have chosen to try and “kill the unions.” In the face of this solidarity among union workers, union rights activist and pro-union politicians is imperative.
Although we hope that Supreme Court makes the right decision and upholds the right to collect a fair share fee, the attorneys at Allotta | Farley will be prepared to implement effective strategies to maintain union membership numbers if the right-wing judges on the Court have their way. Pay attention to this space for more news on Friedrichs as it develops. Allotta | Farley is here to aid non-union and union employees alike in employment matters. If you have questions about your rights or are facing adverse employment action, please do not hesitate to contact us.

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