Opinion ID: 2709494
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Heading: Remedial scope of a benefits claim under

Text: § 1132(a)(1)(B) An ERISA § 502(a)(1)(B) claim is “essentially a contract remedy under the terms of the plan.” Ponsetti v. GE Pension Plan, 614 F.3d 684, 695 (7th Cir. 2010); see also Jones v. Am. Gen. Life & Accident Ins. Co., 370 F.3d 1065, 1069 (11th Cir. 2004); Burstein v. Ret. Account Plan for Emps. of Allegheny Health Educ. & Research Found., 334 F.3d 365, 381 (3d Cir. 2003) (“Claims for ERISA plan benefits under ERISA § 502(a)(1)(B) are contractual in nature.”); Estate of Bratton v. Nat’l Union Fire Ins. Co. of Pittsburgh, Pa., 215 F.3d 516, 523 (5th Cir. 2000). The Supreme Court has explained that the remedy provided in § 1132(a)(1)(B) is designed “to protect contractually defined benefits,” Russell, 473 U.S. at 148, and in keeping with its contract-law foundations, the cause of action offers typical contract forms of relief, including recovery of benefits accrued or otherwise due, declaratory judgments to clarify plan benefits, and injunctions against future denial of benefits, id. at 146-47. The claim is governed by a federal common law of contract keyed to the policies codified in ERISA. Mathews v. Sears Pension Plan, 144 F.3d 461, 465 10 No. 12-1256 (7th Cir. 1998) (“[T]he relevant principles of contract interpretation are not those of any particular state’s contract law, but rather are a body of federal common law tailored to the policies of ERISA.”). The insurance companies argue that the phrase “benefits due . . . under the terms of the plan” means only those benefits specifically listed in plan documents and not benefits guaranteed under state law such as section 632.87(3). See generally Kennedy v. Plan Admin. for DuPont Sav. & Invest. Plan, 555 U.S. 285, 300-04 (2009) (explaining the “plan documents rule,” under which plan administrators are required to follow plan documents). The district court sidestepped this argument, having concluded that the insurance companies cannot be sued at all under § 1132(a)(1)(B). We cannot bypass the point; it’s a necessary predicate to our conclusion that the insurance companies are proper defendants on the plaintiffs’ benefits claim. An ERISA “plan” is an unwritten “scheme” or “set of rules” regarding the provision of employee benefits. Pegram, 530 U.S. at 223 (“Rules governing collection of premiums, definition of benefits, submission of claims, and resolution of disagreements over entitlement to services are the sorts of provisions that constitute a plan.”). Once the plan is conceived, it must be “established and maintained pursuant to a written instrument” and “provide for one or more named fiduciaries who jointly or severally shall have authority to control and manage the operation and administration of the plan.” 29 U.S.C. § 1102(a)(1). No. 12-1256 11 With insurance-based plans, however, “confusion is all too common in ERISA land; often the terms of an ERISA plan must be inferred from a series of documents[,] none clearly labeled as ‘the plan.’ ” Health Cost Controls of Ill., Inc. v. Washington, 187 F.3d 703, 712 (7th Cir. 1999); see also Admin. Comm. of Wal–Mart Stores, Inc. v. Gamboa, 479 F.3d 538, 542 (8th Cir. 2007) (“[I]dentifying ‘the plan’ is not always a clear-cut task.”). We sometimes equate the ERISA “plan” with the insurance policy. See, e.g., Raybourne v. Cigna Life Ins. Co. of N.Y., 576 F.3d 444, 448 (7th Cir. 2009) (describing an insurance policy as “the original plan”). More commonly, however, we refer to an insurance policy as a “plan document” that implements the plan. See, e.g., Ruiz v. Cont’l Cas. Co., 400 F.3d 986, 991 (7th Cir. 2005); Health Cost Controls, 187 F.3d at 712. The Supreme Court has held that when an ERISA plan includes an insurance policy, the requirements imposed by state insurance law become plan terms for purposes of a claim for benefits under § 1132(a)(1)(B). See UNUM Life Ins. Co. of Am. v. Ward, 526 U.S. 358, 375-76 (1999). In Ward the defendant insurer argued—just as the insurers do here—that only a written plan term can be enforced under § 1132(a)(1)(B). Id. at 375. The Supreme Court disagreed, relying on its ERISA preemption caselaw holding that “state laws mandating insurance contract terms are saved from preemption under § 1144(b)(2)(A).” Id. (citing Metro. Life Ins. Co. v. Massachusetts, 471 U.S. 724, 758 (1985)). Section 1144(b)(2)(A) is an exception to ERISA’s general preemption rule and provides that “nothing in this subchapter shall be construed to exempt or relieve any person from 12 No. 12-1256 any law of any State which regulates insurance.” The Court flatly rejected the insurer’s position, commenting that it “overlooks controlling [preemption] precedent and makes scant sense” and would leave the states “powerless to alter the terms of the insurance relationship in ERISA plans.” Id. at 375-76. Under the insurance company’s view of things, “insurers could displace any state regulation simply by inserting a contrary term in plan documents.” Id. at 376. That result, the Court said, “would virtually ‘rea[d] the saving clause out of ERISA.’ ” Id. (alteration in original) (quoting Metro. Life, 471 U.S. at 741). To be sure, ERISA fiduciaries must act “in accordance with the documents and instruments governing the plan.” 29 U.S.C. § 1104(a)(1)(D). Moreover, nothing in § 1132(a)(1)(B) gives a court “the power to change the terms of the plan.” CIGNA Corp. v. Amara, 131 S. Ct. 1866, 1876 (2011). But the Court explained in Amara that it will sometimes be necessary to “look outside the plan’s written language in deciding what those terms are, i.e., what the language means.” Id. at 1877. As an example the Court cited Ward, which “permitt[ed] the insurance terms of an ERISA-governed plan to be interpreted in light of state insurance rules.” Id. (citing Ward, 526 U.S. at 377-79). Accordingly, when an employee-benefits plan includes an insurance policy, contract terms mandated by state insurance law become plan terms. See Ward, 526 U.S. at 375-76. In effect, a plan administrator applying state insurance-law requirements “must be said to enforce No. 12-1256 13 plan documents, not ignore them.” Kennedy, 555 U.S. at 301. Accordingly, Wisconsin’s equal-coverage mandate for chiropractic care, section 632.87(3), is a plan term and may be enforced in a claim under § 1132(a)(1)(B).