United of Omaha v. Business Men's Assurance Company of AmericaUnited of Omaha v. Business Men's Assurance Company of America
Business Men’s Assurance Company of America (BMA) appeals from an order of the district court granting summary judgment to United of Omaha (United) in a dispute under Missouri state law over which company was responsible to pay health insurance benefits. BMA argues that the Employee Retirement Income Security Act of 1974 (ERISA),
I. FACTS
The undisputed facts of this case are as follows. BMA issued a group health insurance policy to Western Water Management, Inc. (Western) for the benefit of Western’s employees, effective January 1, 1989. Western’s group policy was a welfare plan subject to ERISA. During the time of its coverage, one of Western’s employees, Clyde Jones, became totally and permanently disabled, and as a result, Jones experienced a reduction in hours of employment. This was a “qualifying event” under the Consolidated Omnibus Budget Reconciliation Act (COBRA),
Western replaced the BMA policy with an insurance policy issued by United, effective December 1, 1990. Jones began paying monthly premiums to United on that date and was thereafter covered as a COBRA eontinuee under the United policy.
During the period between December 1, 1990 and December 1, 1991, the 12-month period following BMA’s policy’s termination, a number of health care providers presented bills to United for Jones’s medical expenses. United paid the bills but later sought reimbursement from BMA contending that BMA was responsible for the expenses pursuant to Missouri law that governs the discontinuance and replacement of insurance for disabled individuals.
See
United brought this action against BMA seeking damages under Missouri law for the hospital and medical expenses United had paid on behalf of Jones during the 12-month period following the termination of BMA’s policy. The parties filed a series of motions for summary judgment, making arguments on liability, certain affirmative defenses, and damages. The district court granted United’s motions for summary judgment, holding that United’s state-law claim was not preempted by ERISA and, according to Missouri law, BMA is liable for Jones’s medical and hospital expenses incurred from December 1,1990, through December 1, 1991. The court calculated the damages based upon the full amount of medical expenses United had paid, plus prejudgment interest.
BMA appeals, asserting a number of arguments. First, BMA contends that the district court erroneously interpreted
II. Standard of Review
We review the district court’s grant of summary judgment de novo, applying the
III. Statutory Interpretation
To determine whether United has a cause of action that is preempted by ERISA, we must interpret the state statute on which the cause of action is based. The district court interpreted the state statute to require BMA, as a prior carrier of group health insurance, to provide Jones an extension-of-benefits for 12 months following the termination of the policy, regardless of whether Western had secured replacement coverage. The court then looked at BMA’s policy, which provided an extension for medical expenses, without payment of a premium, “1) for up to 3 months after coverage terminates for any sickness or injury; and 2) for up to 9 more months for the sickness or injury causing the total disability,” but which also stated that the extension of benefits would be terminated on “[t]he date the [cjovered [pjerson is covered under any other group policy or employer-funded plan.” (J.A at 76.) Finding this termination provision of the policy to be incompatible with Missouri law, the district court held that it was void. BMA argues that the extension-of-benefits coverage provided in its policy does not violate the state statute because it is reasonable, within the meaning of section 376.438.1, for BMA to refuse to extend benefits after the disabled person is covered by a replacement policy.
Our primary objective in interpreting the Missouri statute is to ascertain the legislative intent from the statutory language and, if possible, to give effect to that intent.
Rothschild v. State Tax Comm'n of Mo.,
Section 376.438.1 of the Missouri Revised Statutes provides:
Every group policy or other contract subject to sections 376.431 to 376.442, or under which the level of benefits is hereafter altered, modified or amended, must provide a reasonable provision for extension of benefits in the event of total disability at the date of any termination or discontinuance of the group policy or contract, regardless of the reason for the termination or discontinuance, as required by the following subdivisions of this subsection[.]
This provision has three subdivisions. Subdivision (3) states, in relevant part:
In the ease of hospital or medical expense coverages ...,' a reasonable extension of benefits or accrued liability provision is required. Such a provision will be considered reasonable if it provides an extension of at least twelve months under major medical and comprehensive medical type coverages....
To interpret the language of
When one carrier’s contract replaces a plan of similar benefits of another carrier, the prior carrier remains liable only to the extent of its accrued liabilities and extensions of benefits. The position of the priorcarrier shall be the same whether the group policyholder or other entity secures replacement coverage from a new carrier, self-insurer, or foregoes the provision of coverage.
The statute requires succeeding carriers to provide coverage for individuals who are not eligible under the succeeding carrier’s policy, but who were validly covered under a benefit extension on the date of the prior carrier’s discontinuance and who are in the class of persons eligible for coverage under the succeeding carrier’s policy. Under this required coverage, the succeeding carrier’s obligation to pay benefits is measured by the applicable benefits under the prior carrier’s plan, reduced by the benefits payable by the prior carrier. Id. § 376.441(1); see also id. § 376.441(3) (measuring the succeeding carrier’s obligation to pay expenses related to preexisting conditions by the lesser of (1) the benefits of the succeeding carrier’s policy without regard to any limitation for preexisting conditions or (2) the benefits of the prior carrier’s policy). The succeeding carrier must provide this coverage until the earliest of several dates, one of which is when the period of extension or accrued liability by the prior carrier has terminated. Id. § 376.441(2)(c). When the situation arises requiring a determination of the prior carrier’s benefits, those benefits are to be determined under the prior carrier’s plan, “as if coverage had not been replaced by the succeeding carrier.” Id. § 376.441(5).
Section 376.441 reveals that BMA’s policy of providing extended benefits only until replacement coverage is secured is not “reasonable” within the meaning of
We also note that BMA’s interpretation of what is reasonable misconstrues the nature of the
We therefore hold that BMA was primarily obligated to provide extended benefits to Jones for a reasonable period of time. We further hold that BMA cannot avoid this requirement merely because Western secured replacement coverage for Jones. Because of our disposition of this case -under the preemption analysis below, we need not consider the issues of whether the language in
IV. ERISA Preemption
BMA argues that United’s claim is preempted by ERISA, both because the Missouri statutes are in conflict with COBRA and because United styles its claim as a common-law subrogation claim. ERISA regulates employee pension and welfare plans. While ERISA imposes various procedural
As with all preemption analysis, our task is to ascertain congressional intent in enacting the federal law. Id. In enacting ERISA, Congress set out:
“to ensure that plans and plan sponsors would be subject to a uniform body of benefits law; the goal was to minimize the administrative and financial burden of complying with conflicting directives among States or between States and the Federal Government ..., [and to prevent] the potential for conflict in substantive law ... requiring the tailoring of plans and employer conduct to the peculiarities of the law of each jurisdiction.”
New York Conference of Blue Cross v. Travelers Ins.,
— U.S. -, -,
The “relates to” language of the preemption clause is meant to provide some boundaries to the scope of preemption, however, and the question of whether state law is connected with ERISA is not to be carried to its infinite, logical limits.
New York Conference of Blue Cross,
— U.S. at -,
If a state law does in fact fall within the scope of ERISA’s preemption clause, it may nonetheless be excepted under what has become known as the “savings clause.”
Regulation of the insurance industry may exist both in ERISA and in state law. In such circumstances, “ERISA leaves room for complementary or dual federal and state regulation.”
John Hancock Mut. v. Harris Trust & Sav. Bank,
With this legal framework in mind, we turn now to BMA’s arguments that Missouri’s extension-of-benefits statute and this cause of action are preempted.
A Preemption and Missouri Revised Statute 376.438
Applying the same preemption analysis as set forth above, the district court con-eluded that ERISA does not preempt
BMA contends that the district court’s conclusion is flawed because the court failed to consider adequately the limitations on the savings clause announced in
Pilot Life,
The precise requirement at issue in this case is the extension-of-benefits requirement of Missouri Revised Statute,
Thus, we turn to the question of whether
BMA’s assertion that United subjected itself to COBRA requirements by issuing a group policy to Western misses the mark. Western, the plan sponsor, fulfilled its COBRA obligations by securing an opportunity for Jones to obtain continued coverage through United. BMA’s claims that United became a fiduciary under COBRA and that United has continuing duties under COBRA (such as giving Jones notice) simply do not affect BMA’s duty to provide an extension of benefits under Missouri state insurance law.
BMA also submits a conflict-preemption argument based on COBRA’s requirement that the continuing coverage provided to disabled individuals be identical to the coverage provided to similarly situated beneficiaries to whom a qualifying event has not occurred.
See
29 U.S.C: § 1162(1): BMA contrasts this requirement with the language in
We recognize that our holding negates the provision in BMA’s policy providing for a termination of extended benefits when the recipient obtains other coverage, but this provision conflicts with the substance of state insurance law. Having already concluded that the state extension-of-benefits statute is an insurance regulation saved from preemption and fully compatible with the language and spirit of ERISA, we will not now find that a conflicting provision in BMA’s ERISA plan overrides the state statute. To do so would be to open the door for insurance companies to avoid any state insurance law simply by including a contrary provision in their group ERISA welfare plans.
Arkansas Blue Cross & Blue Shield,
In summary so far, we conclude that
B. Preemption and the Common Law of Subrogation
Whether United’s
cause of action
is preempted presents yet another question. United brought this cause of action under state common law as a subrogee.
4
United’s theory is that it became subrogated to the rights of Jones when it paid claims for which BMA was primarily liable. Relying on
Baxter,
In
Baxter,
the beneficiary' had been awarded damages from a tortfeaser in addition to the medical benefits he had received under an ERISA plan. When the plan’s insurer attempted to enforce a plan provision creating a right of subrogation in favor of the insurer against the beneficiary, the beneficiary pointed to state law precluding such subrogation. We found that the state anti-subrogation law prevented the plan administrator from exercising its rights under the plan to obtain reimbursement from the beneficiary for the medical expenses paid. Because the state law directly impacted the structure of the ERISA plan, we concluded that it was related to the plan.
See Arkansas BCBS,
The district court in this case distinguished Baxter and rejected BMA’s preemption argument on the basis that United’s subrogation claim is not related to the plan. The court stated:
Although the terminology is the same, the subrogation involved in Baxter and that involved here are entirely different. The subrogation at issue in Baxter related to the rights and obligations running between the insurer and the insured. It thus “relate[d] to an employee benefit plan,” and required analysis under the McCar-ran-Ferguson Act. By contrast the subro-gation involved here is unrelated to the substantive provisions of the insurance policy; it is simply an equitable principle for recovering a claim from one who ought to have paid it.
(Appellant’s Adden. at A-5.)
We agree that in some respects, this case is quite different from Baxter. Here, the dispute is between two insurance companies over which company is responsible to pay for certain benefits. This particular state-law claim does not affect either the amount of benefits due to Jones or any reimbursement from him to the plan. This subrogation claim implicates the allocation of liability between prior and succeeding insurance carriers under state insurance law.
Despite these distinctions from
Baxter,
we nonetheless conclude that ERISA preempts United’s claim. Under Missouri law, “[i]t is ... well established that in [a subrogation] action a party makes a claim through a derivative right acquiring no greater rights in law or equity than the party for whom it was substituted and therefore, cannot make a claim its subrogor could not make.”
Stoverink v. Morgan,
To be sure, subrogation is an equitable doctrine founded on principles of justice, and BMA was obligated under Missouri law to provide a reasonable extension of benefits.
See American Nursing Resources, Inc. v. Forrest T. Jones & Co.,
V. Conclusion
For the above reasons, we affirm the district court in its conclusion that ERISA does not preempt
RICHARD S. ARNOLD, Chief Judge, concurs in the judgment.
Notes
. "An employee welfare-benefit plan or welfare plan is defined as one which provides to employees 'medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident disability [or] death,' whether these benefits are provided ‘through the purchase of insurance or otherwise.'"
Metropolitan Life Ins. Co. v. Massachusetts.
. The savings clause is limited, in turn, by the "deemer clause,”
FMC Corp. v. Holliday,
. We note that Missouri has a continuing coverage statute that is in fact analogous to COBRA,
. Because United is not a "participant” or "beneficiary, " United has no standing to bring an ERISA claim.