One of the key aspects of determining whether ERISA fiduciary law applies has to do with whether the benefit plan at issue is an ERISA-covered plan. ERISA provides an exemption from its applicability under 29 C.F.R. Section 2510.3-1(j) for certain "group or group-type insurance programs." If a plan meets all four requirements of this exemption, then the plan is not an ERISA-covered plan, but will be governed by state law.
In general, in order to fall under this safe harbor (and fall out of ERISA), one of the requirements of the safe harbor is that no contributions be made by the employer, i.e. if the employer is making contributions to the plan, then it is an ERISA-covered plan. Thus, because many disability plans are funded either partially or fully by the employer, they are covered by ERISA.
In the recent Sixth Circuit case of Helfman v. GE Group Life Assurance Company, et al., a participant had challenged the district court's decision that the plan was covered by ERISA because the participant sought to get out from under the ERISA banner of deference afforded the plan administrator's decision. The district court had ruled that the plan administrator had not abused its discretion and upheld the insurer's termination of the participant's benefits.
In the case before the court, the participant had reimbursed the employer for contributions made on his behalf, even though contributions made on behalf of other participants to the plan had not been reimbursed. The participant argued that, because the employer was not making contributions to the plan on his behalf, ERISA should not apply in the case of his benefits under the plan, even though he agreed that ERISA would apply to the plan with respect to those participants on whose behalf the employer did make contributions. While it was an interesting argument, the Sixth Circuit rejected it, upholding the district court's decision that ERISA applied and holding that the four requirements of the safe harbor exemption had not been met. The Sixth Circuit opined as follows:
Accordingly, we hold that if an employer contributes to any employee’s payment of premiums, ERISA must apply to the entirety of the particular insurance program, regardless of whether one or more employees pays his own premiums in full. (Emphasis added.)
And:
To that end, we find that the ERISA policy of uniform regulation dictates a finding that a single plan may not be variously governed by both ERISA and state law, depending on the particular employee in question.
After reaching the decision that ERISA applied, the Sixth Circuit then went on, using the MetLife v. Glenn conflicts analysis, to hold that the insurer had abused its discretion. In finding that the insurer had failed to provide "explanations of its reasons" for making certain determinations leading to the termination of the participant's benefits, the court held that the insurer/fiduciary had not engaged in a "deliberate and principled reasoning process."
Please note that, in reaching its decision, the court cites the fact that the insurer used "a combination of in-house consultants and independent consultants" in concluding that the insurer was "conflicted" under Glenn.
Conclusion: The case illustrates the complexity of the law surrounding the issue of ERISA applicability. Suppose that a disability plan is designed to fall out of ERISA through the safe harbor, but the employer on an ad hoc basis decides to
reimburse even just one participant with respect to his or her contributions under the plan. Under the holding of the case, a plan might suddenly become an ERISA plan based on the reimbursement of a single participant.
The case is also another illustration of how fiduciaries should engage in a "deliberate and principled reasoning process" in reaching a claims decision in order to find refuge under the Firestone standard of review.