State News : New Jersey

The ERISA Lien – – A Federal “Partner” In State Workers’ Compensation Litigation

By:  Alfred Vitarelli, Esq., Shareholder, Stark & Stark

If the workers’ compensation practitioner reading this otherwise dry blog finds his/her mind wandering to more exciting topics, let your mind focus on that ominous line from the 1987 classic “Fatal Attraction:” I will NOT be IGNORED!”

No, I am not comparing the great acting of Glenn Close to ERISA. I am, however, making the important point that like Close’s character, ERISA must never be ignored.

I’ll begin discussing ERISA liens by presenting a scenario played out with distressing frequency in New Jersey workers’ compensation courts. Petitioner’s attorney informs the Judge that a private disability plan (the plan) has provided treatment in the denied claim presently before the Court. An agreement has been reached with Respondent to settle the claim on a Section 20 dismissal. However, the plan has asserted a substantial lien for payments made on behalf of the petitioner. To make matters worse, the plan has not to date provided detailed billing records, medical documentation, etc., which the parties hope will allow the reduction of the amount of the lien, and this is delaying the settlement. Accordingly, petitioner’s attorney will be filing a motion requesting the court to rule out the lien if the plan does not appear on the return date of the motion.

See any problems with the above scenario? Well, yes. And yes.

First yes:  based on the facts given above there has been no consideration as to the status of the plan lien; since this is a discussion of ERISA, the parties are unaware if the plan is covered by ERISA. And why is this important? Because ERISA plans are created by federal law, and thus are subject only to federal jurisdiction. That’s why.

Second yes: because any order entered against an ERISA plan by a state court judge is ultra vires (meaning, acting beyond one’s legal power). Since ERISA plans are only subject to federal jurisdiction, they can ignore any such order as discussed above and sue in federal court to recover the amount of its lien. That’s why #2.

Ok, let’s get down to a serious discussion of ERISA. (Actually, I think this has been serious all along, but I’m sure there are those who will disagree).

Exactly what is ERISA? The Employment Retirement Income Security Act of 1974, ERISA, is a federal law which sets minimum standards for most voluntarily established pension, health and disability plans in private industry. ERISA allows an employer to establish self-funded plans. These plans are employee benefits which pay claims through either the assets of the employer or through a trust which is funded by contributions from the employer and employees. An ERISA health plan differs from a traditional health insurance policy which is purchased through premiums to provide coverage. ERISA expressly pre-empts “any and all state laws insofar as they may now or hereafter relate to any employee benefit plan.”

So, having said that, who or what entities are covered by ERISA? ERISA applies to private industry. In general, ERISA does not cover group health plans established or maintained by government entities, churches for their employees, or plans which are maintained solely to comply with workers’ compensation, unemployment or disability laws. A prime example of what plans are covered by ERISA are those provided to employees pursuant to a collective bargaining agreement between a labor union and an employer. These plans are funded either entirely by the employer or by contributions from the employees as called for by the employer/union agreement.

Ok, now we know what an ERISA plan is, and (hopefully) understand the necessity of directly addressing liens asserted by these plans. So how can an attorney faced with a private plan lien determine if the plan is covered by ERISA?  This can’t be determined by just looking at the client’s benefit card; they don’t say “This plan is covered by ERISA.”  When the status of a lien is in doubt the best way is to request from the Plan Administrator the Summary Plan Description, IRS Form 5500. The Administrator is required to furnish a copy of the latest updated plan documents, including the Master Plan Document. These should be reviewed carefully, since an ERISA plan must clearly state the existence of a right to recovery. NOTE: Never assume that because the lien is asserted by a “traditional” insurance carrier such as Aetna, Cigna, BlueCross/Blue Shield, etc., that the plan is paid by premiums and is therefore not a private benefit plan covered by ERISA. Such insurance carriers do act as TPAs for ERISA plans. When in doubt ask for the IRS form 5500. Another method to obtain the form 5500 is to register online at www.freeerisa.com. I have not used this yet, but some attorneys find this a very convenient method to obtain this information.

Federal Jurisdiction – what are the implications if a lien is not honored?

Earlier in this blog it was noted that ERISA plans are only subject to federal jurisdiction; the doctrine of federal preemption applies as well. If an ERISA lien is not honored when asserted in a workers’ compensation case the plan provider may file an action in federal court to enforce its right of subrogation as contained in the plan. This is authorized by Section 502(a)(3) creating an equitable form of relief in the recovery of payments. This equitable right of recovery was most famously recognized by the U.S. Supreme Court case of US Airways Inc. v. McCutchen, 133 S. Ct.1537 (2013). Here, the Court held that an equitable lien is created by the language of an ERISA Plan, and the language of the Plan controls absolutely, even to the exclusion of common-law principles of unjust enrichment, the make-whole doctrine and the common-fund rule.

Please note carefully, however, that McCutchen holds the language of the Plan controls. While most practitioners will be aware of the McCutchen decision, fewer know the ultimate outcome of the litigation. After the Supreme Court rendered its decision, it remanded the case to the lower court to review the language of the Plan documents. Surprise, surprise! It turns out that the attorneys in the case did not review the Plan documents before the Supreme Court remand. The lower court found that while the Summary Plan Description supported the recovery of the full lien, the Master Plan Document did not. As a result, US Airways was only entitled to a recovery on a small portion of the overall settlement below. ALWAYS READ THE DOCUMENTS!

The above points should make it clear that in ANY situation where a petitioner received unauthorized treatment through a private benefit plan his/her attorney must be aware as early as possible in the litigation whether the plan is covered by ERISA. There are too many pitfalls which may be encountered by ignoring the status of these Plans (including recovery of the lien by attaching attorney fees.) Of course, non-ERISA plan liens must also be addressed, but they at least may be covered by state laws on subrogation, something outside the topic of this blog.

Before ending, I feel it necessary to discuss the potential role of the respondent attorney in these situations. I can hear most of you already: ”what role? there is none…petitioner’s problem….not my fees that can be attached…that lien is just a darn nuisance, my role is to make it go away so I can close the file.” OK, so maybe that last comment was a stretch, but the others are heard…and wrong. Remember the definition of an ERISA plan? How it is funded? Entirely by employer or by employer and employees? Right, now you get it. Employer = Respondent (in many if not most cases.)

So, having also been a respondent attorney for many years, I feel that the employer should always be consulted in ERISA lien situations before settlement discussions begin considering the financial implications of the Plan paying for possibly work-related treatment. I have definite ideas about what approaches to take, but I’ll leave it to others to fill in the blanks.

Please keep in mind that both this blog and the study of ERISA liens generally are works in progress. This blog is intended to raise the awareness of the workers’ compensation bar of the necessity of seriously addressing ERISA liens, not to serve as a how-to guide in every case. Each case will have its own unique issues, so always keep this in mind, and whenever in doubt, request the documents, don’t ignore!!

(Editor’s Note:  Many thanks to Attorney Al Vitarelli for sharing this highly entertaining and educational blog on a topic most practitioners knew very little about but one that we all need to pay close attention to).

Editor:

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John H. Geaney, Esq., is an Executive Committee Member and a Shareholder in Capehart Scatchard's Workers’ Compensation Group.  Mr. Geaney concentrates his practice in the representation of employers, self-insured companies, third-party administrators, and insurance carriers in workers’ compensation, the Americans with Disabilities Act and Family and Medical Leave Act. Should you have any questions or would like more information, please contact Mr. Geaney at 856.914.2063 or by e‑mail at jgeaney@capehart.com.