Employee Retirement Income Security Act - ERISA Pre-emption

ERISA Pre-emption

ERISA Section 514 preempts all state laws that relate to any employee benefit plan, with certain, enumerated exceptions. The most important exceptions — i.e. state laws that survive despite the fact that they may relate to an employee benefit plan — are state insurance, banking, or securities laws, generally applicable criminal laws, and domestic relations orders that meet ERISA's qualification requirements.

A major limitation is placed on the insurance exception, known as the "deemer clause", which essentially provides that state insurance law cannot operate on employer self-funded benefit plans. The Supreme Court has created another limitation on the insurance exception, in which even a law regulating insurance will be pre-empted if it purports to add a remedy to a participant or beneficiary in an employee benefit plan that ERISA did not explicitly provide.

A three-part analysis is used to decide whether ERISA preempts state law. First, preemption is presumed if the state law “relates to” any employee benefit plan. Second, a state law relating to an employee benefit plan may be protected from preemption under ERISA if it regulates insurance, banking, or securities. The third step of the ERISA preemption analysis concerns the “deemer” clause. State insurance regulation may be saved only to the extent that it regulates genuine insurance companies or insurance contracts. As a result, a state may not “deem” an employee benefit plan to be an insurance plan in an effort to sidestep preemption if the benefit plan would not otherwise meet the requirements as an insurance company or contract. The “deemer” clause therefore restricts the use of the “savings” clause to conventionally insured employee benefit plans.

The result is that the only remedy available to a covered person who has been denied benefits or dropped from coverage altogether is to seek an order from a federal judge (no jury trial is permitted) directing the Plan (in actuality the insurance company that underwrites and administers it) to pay for "medically necessary" care. If a person dies before the case can be heard, however, the claim dies with him or her, since ERISA provides no remedy for injury or wrongful death caused by the withholding of care.

Even if benefits are improperly denied, the insurance company cannot be sued for any resulting injury or wrongful death, regardless of whether it acted in bad faith in denying benefits. Insurers operating ERISA plans enjoy several immunities not available to other types of insurance companies. ERISA preempts all conflicting state laws, including state statutes prohibiting unfair claims practices and causes of action arising under state common law for insurance bad faith. There is no right to a jury trial in ERISA benefits actions. Although Americans normally take for granted the right to testify on their behalf, plaintiffs have no right to present live testimony in ERISA bench trials, in which the judge simply reads through the documents which formed the record originally before the ERISA plan administrator and performs de novo review. Finally, punitive damages are not allowed in actions for ERISA benefits.

It has been argued that in the case of health benefits, the effect of all of this may paradoxically have been to leave plan participants worse off than if ERISA had not been enacted.

Many persons included among the some 47 million people presently without health care coverage in the United States are former ERISA "subscribers", insurance terminology for Plan beneficiaries, who have been denied benefits-usually on the ground that the prescribed care is not medically necessary or is "experimental"-or dropped from coverage, often because they have lost their jobs due to the very illness for which care was denied.

Many consumer and health care advocates have called for a "restoration of the freedom of contract enforcement," to the 75% of Americans insured under these work place group plans-in effect, a repeal of the ERISA pre-emption. Permitting these insured persons access to customary state remedies (98% of all civil disputes are resolved in state courts) would, they contend, result in a substantial reduction in arbitrary denial of care benefits, simultaneously alleviating a major burden on state Medicaid systems and clogged federal court dockets.