OPINION
Defendant-Appellee Ken Ross is the Commissioner (“Commissioner”) of the
I. BACKGROUND
A. Background of the Rules
The parties stipulated to the following pertinent facts for the purpose of the cross-motions for summary judgment. (Stip. Facts, Joint Appendix (“JA”) 44.)
OFIS is responsible for licensing, examining, and supervising insurers and nonprofit health-care corporations doing business in the State of Michigan. To this end, OFIS’s authority includes the power to disapprove insurance policy forms, and documents associated with such forms, which are filed by insurers and nonprofit health-care corporations doing business in Michigan. Pursuant to this authority, OFIS promulgated administrative rules, Mich. Admin. Code Rules 500.2201-500.2202 and 550.111-550.112, which generally prohibit insurers and nonprofit health-care corporations from issuing, advertising, or delivering to any person in Michigan, a policy, contract, rider, indorsement, certificate, or similar contract document that contains a discretionary clause and provide that any such clause is void and of no effect. The rules define discretionary clauses as:
[A] provision in a form that purports to bind the claimant to or grant deference in subsequent proceedings to the insurer’s decision, denial, or interpretation on terms, coverage, or eligibility for benefits including, but not limited to, a form provision that does any of the following:
(i) Provides that a policyholder or other claimant may not appeal a denial of a claim.
(ii) Provides that the insurer’s decision to deny policy coverage is binding upon a policyholder or other claimant.
(iii) Provides that on appeal the insurer’s decision-making power as to policy coverage is binding.
(iv) Provides that the insurer’s interpretation of the terms of a form is binding upon a policyholder or other claimant.
(v) Provides that on appeal the insurer’s interpretation of the terms of a form is binding.
(vi) Provides that or gives rise to a standard of review on appeal that gives deference to the original claim decision.
(vii) Provides that or gives rise to a standard of review on appeal other than a de novo review.
Mich. Admin. Code Rules 500.2201(b) and 550.111(c).
The rules took effect June 1, 2007. Given that employee-benefit plans established or maintained under ERISA commonly contain discretionary clauses, the rules would prohibit any entity covered by them from “issuing, advertising, or delivering to any person in the State of Michigan, including an employee benefit plan subject to ERISA, an underwritten policy or certificate that includes a discretionary clause.” (JA 46.)
Plaintiffs American Council of Life Insurers and America’s Health Insurance Plans are national trade associations representing health plans, health insurers, and life insurers that conduct business in Michigan. Both trade associations “advocate public policies on behalf of their members in legislative, regulatory, and judicial forums at the state and federal levels.” (JA 47.) Their members offer a variety of insurance products, including “health care coverage, medical expense insurance, long-term care insurance, disability income insurance, [and] dental insurance.” (Id.) Plaintiff Life Insurance Association of Michigan represents life insurance companies licensed in Michigan that provide similar insurance products to Michigan customers that sponsor employee benefit plans subject to ERISA.
Because the Insurance Industry is subject to certain rules promulgated by OFIS, the Insurance Industry “would be affected if the [r]ules are upheld because some of their members have in the past used policy forms approved by OFIS that had discretionary clauses and the members may wish to use such clauses in future policy forms submitted to OFIS.” (JA 48.) Similarly, many of the customers of the Insurance Industry’s members “would be affected if the [r]ules are upheld because they have also purchased OFIS approved policies containing discretionary clauses to fund their employee benefit plans, and many may wish to do so again in the future.” (Id.)
B. Procedural Background
On July 2, 2007, the Insurance Industry filed suit against OFIS, seeking declaratory relief that the rules do not govern the administration and enforcement of the terms of employee benefit plans subject to ERISA, and injunctive relief prohibiting the Commissioner and OFIS from enforcing the rules with respect to insurance policies issued for the purpose of funding or otherwise providing benefits in connection with plans subject to ERISA. Following discovery, both parties moved for summary judgment, with the Insurance Industry arguing, inter alia, that (1) the rules are preempted by ERISA because they interfere with that statute’s objectives, and (2) the rules do not fall within the ambit of ERISA’s savings clause, 29 U.S.C. § 1144(b)(2)(A). The district court rejected each of these arguments, granting summary judgment in favor of the Commissioner.
II. DISCUSSION
A. Standard of Review
We review the district court’s grant of summary judgment on the issue of ERISA preemption de novo.
Millsaps v. Thompson,
B. ERISA
ERISA regulates, among other things, employee welfare benefit plans that provide medical, surgical, or hospital care, or benefits in the event of sickness, accident, disability, or death through the purchase of insurance. ERISA § 3(1), 29 U.S.C. § 1002(1). ERISA permits a participant or beneficiary to bring a civil action (1) “to recover benefits due to him under the terms of his plan,” (2) “to enforce his rights under the terms of the plan,” or (3) “to clarify his rights to future benefits under the terms of the plan.” ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). “This provision is relatively straightforward. If a participant or beneficiary believes that benefits promised to him under the terms of the plan are not provided, he can bring suit seeking provision of those benefits.”
Aetna Health Inc. v. Davila,
Because “Congress enacted ERISA to protect ... the interests of participants in employee benefit plans and their beneficiaries,” it set out “substantive regulatory requirements for employee benefit plans and [provided] for appropriate remedies, sanctions, and ready access to the Federal Courts.”
Id.
at 208,
C. Express ERISA Preemption and the Savings Clause
The parties agree that the rules relate to an employee-benefit plan and, therefore, fall under ERISA’s express preemption clause.
See
ERISA § 514(a), 29 U.S.C. § 1144(a). There is also no dispute that the rules do not regulate banking or securities. The rules therefore are saved from federal preemption only if they regu
1. The Rules are Directed Toward Entities Engaged in Insurance.
In
Miller,
the Court emphasized that laws of general application that may have some bearing on insurers do not satisfy the first prong.
Furthermore, under the plain language of the rules, any insurer who wishes to provide insurance in Michigan must submit its insurance forms to the Commissioner for review and may not include a discretionary clause in such forms; if an insurer fails to comply with this requirement, the insurance contract is void and of no effect.
See
Mich. Admin. Code R. 500.2202. Thus, the rules specifically control the terms of insurance policies by specifying the permissible contract terms.
See FMC Corp. v. Holliday,
Regardless, the Insurance Industry contends that the rules are not so directed at insurers inasmuch as the effect of the rules is felt primarily by the fiduciary who administers the plan, rather than by the insurer. We disagree. In reaching our decision, we are guided by the Supreme Court’s rejection of a similar argument in
2. The Rules Substantially Affect the Risk-Pooling Arrangement.
The Insurance Industry’s next challenge to the rules focuses on whether the rules substantially affect the risk-pooling arrangement between insureds and insurers as required by
Miller. Miller,
First, the rules directly control the terms of insurance contracts by prohibiting insurers and insureds from entering into contracts that include discretionary clauses and prohibiting enforcement of
Second, under the rules, insurers can no longer invest the plan administrator with unfettered discretionary authority to determine benefit eligibility or to construe ambiguous terms of a plan. Prohibiting plan administrators from exercising discretionary authority in this manner “dictates to the insurance company the conditions under which it must pay for the risk it has assumed.”
Miller,
We therefore conclude that the rules regulate insurance because they substantially affect the risk-pooling arrangement between insureds and insurers. As such, the rules fall within the scope of ERISA’s savings clause.
D. Conflict Preemption
The Insurance Industry argues that the rules cannot be saved from preemption because they conflict with ERISA’s civil enforcement provisions. Even if a state law regulates insurance such that it falls within ERISA’s savings clause, it may nevertheless be preempted by that statute’s § 502(a) civil enforcement provisions. In relevant part, § 502(a) allows an ERISA plan participant or beneficiary to file a civil action “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). Accordingly, ERISA’s civil enforcement provisions are the “sort of overpowering federal policy that overrides a statutory provision designed to save state law from being preempted.”
Rush Prudential,
ERISA § 514(b)(2)(A) must be interpreted in light of the congressional intent to create an exclusive federal remedy in ERISA § 502(a). Under ordinary principles of conflict pre-emption, then, even a state law that can arguably be characterized as ‘regulating insurance’ will be pre-empted if it provides a separate vehicle to assert a claim for benefits outside of, or in addition to, ERISA’s remedial scheme.
However, there is no state-law claim at issue in this case that implicates ERISA’s civil enforcement provisions. The rules do not authorize any form of relief in state courts, either expressly or impliedly; they do not grant a plan participant the ability to “recover benefits under the plan, enforce his rights under the plan, or otherwise clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). Put simply, the rules do not create, duplicate, supplant, or supplement any of the causes of action that may be alleged under ERISA. Nor is there any evidence that the rules serve as an alternative enforcement mechanism, outside of ERISA’s civil enforcement provisions such that the rules permit a plan
E. Conflict With the Purpose of ERISA
Finally, citing the rules’ proscription of a deferential standard of judicial review, the Insurance Industry argues that the rules are preempted because they squarely conflict with ERISA’s policy of ensuring a set of uniform rules for adjudicating cases under ERISA. The rules, according to the Insurance Industry, have no purpose or effect other than to control ERISA litigation. Here, too, we find their argument unavailing.
First, the plain language of ERISA provides nothing about the standard of review in cases brought under the statute’s civil enforcement provisions.
See Rush Prudential,
More importantly, we are guided by the Supreme Court’s rejection of a similar argument in
Rush Prudential.
There, the Supreme Court held that a state statute mandating that benefit denials are subject to de novo review did not conflict with ERISA.
In
Metropolitan Life Insurance Co. v. Glenn,
— U.S. -,
Finally, we observe that
Glenn
provides further support for holding that Michigan’s law is not preempted by ERISA. There, the Court reiterated that a conflict of interest exists when the same insurer is responsible for examining and paying a benefits claim.
Glenn,
Nor is it necessarily the case, as the Insurance Industry suggests, that, if Michigan can remove discretionary clauses, it will be allowed to dictate the standard of review for all ERISA benefits claims. All that today’s case does is allow a State to remove a potential conflict of interest. And while Michigan’s law may well establish that the courts will give de novo review to lawsuits dealing with the meaning of an ERISA plan, it does not follow that they will do so in reviewing the application of a settled term in the plan to a given benefit request.
III. CONCLUSION
For the foregoing reasons, we hold that the Michigan rules fall within the ambit of ERISA’s savings clause and are not preempted by that statute. The summary judgment of the district court is AFFIRMED.
