Scope of ERISA coverage; ERISA plan defined; Employer only plan; Jurisdiction

Article Abstract:

ERISA defines an employee welfare benefit plan as a plan, fund, or program; established or maintained; by an employer, an employee organization, or both through the purchase of insurance or otherwise, for the purpose of providing medical, surgical, or hospital care or benefits or benefits in the event of sickness, accident or disability, for its participants or their beneficiaries. In addition, a reasonable person must be able to ascertain the intended benefits, a class of beneficiaries, the source of financing, and procedures for receiving benefits. The Eleventh Circuit explained, however, that not all welfare benefit plans that meet the five criteria are governed by ERISA. A plan, which provides benefits only to an employer, is not governed by ERISA. To be an ERISA plan, one employee who is not an owner or partner or spouse of the owner must be a participation in the plan. Non-ERISA benefits do not become ERISA benefits because they co-exist alongside ERISA benefits.

Business Aid & Regulation NEC, Employee benefits, Business assistance, Slamen, Herbert, Paul Revere Life Insurance Co.

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ERISA plan defined-Conversion policy not an ERISA plan; Preemption

Article Abstract:

State law claims that have to deal with individual insurance policies transformed from group policies into individual policies are not preempted. While claims involving the ability or right to convert policies from group to individual are subject to ERISA, claims relating strictly to a conversion policy itself can properly be brought under state law. The sole issue before the Court of Appeals was whether ERISA preemption applied to claims arising from the conversion policy. By analyzing the question in light of Congress' two-fold purpose in enacting ERISA, the First Circuit determined that a conversion policy is not an ERISA plan subject to ERSIA regulation and that state law claims arising out of a conversion policy are not preempted by ERISA. If conversion policies were ERIA plans, insurers would be ERISA plan administrators with respect to each policy and would be required to meet ERISA's extensive requirements for filing plan descriptions and detailed reports for each individual conversion policy. Article includes Demars v. CIGNA Corp.

Analysis, Laws, regulations and rules, Insurance claims adjustment, CIGNA Corp., CI, Claims adjustment (Insurance), Actions and defenses, Litigation, Demars, Jeanne

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Focus on plan administration: Health plan reimbursement-offsets

Article Abstract:

In Harris vs Harvard Pilgrim Health Care, the issue involved the insurer's right to recover expenses for which a third party is or may be liable. The case involved a person injured in a motorcycle accident, who may have been intoxicated and speeding at the time of the accident. The family settled the lawsuit against the third party responsible for the accident for a lesser amount than the case might have been worth due to the uncertainty of the outcome due to the allegations of intoxication and speeding. Harvard Pilgrim had obtained a lien entitling it to recover its claim, but the family sued it on the grounds that the lien was excessive. The court held in favor of Harvard Pilgrim, which has clear language about these rights in its plan.

HEALTH SERVICES, Health Maintenance Organizations, HMO Medical Centers, Insurance Regulation, Insurance law, Harris, Michael, Harvard Pilgrim Health Care

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