Originally located at:http://www.thefederation.org/public/Quarterly/Summer00/fairborn.htm
ERISA Preemption Laws & RICO:
Litigation Against Life & Health Insurers
Katherine W. Fairborn
I.
Introduction
The recent Supreme Court determination in Humana v. Forsyth expanded
a policyholder’s ability to bring a RICO claim against his or her insurer.[1]
When this finding is viewed in light of the broad preemptive powers of
ERISA legislation and the concomitant lack of ERISA remedies, it seems
likely that growing numbers of disgruntled policyholders will turn to the
federal RICO laws when suing insurers. This article analyzes recent
case law to determine whether and how the preemption of state law claims
under ERISA encourages federal RICO claims against life and health insurers,
while also permitting plaintiffs’ attorneys to artfully plead ERISA cases.
In one such case recently decided by the Supreme Court, plaintiff’s attorneys
had even alleged that HMO cost-containment measures violated ERISA fiduciary
standards when a patient later developed peritonitis following delayed
diagnostic treatment.[2]
To explore the legitimacy of the author’s premise, this article begins
by exploring recent federal case law construing ERISA. It next examines
the substance of ERISA legislation; what Congress intended under ERISA;
the types of insurance covered by ERISA; and how the statute has
been utilized in policyholder actions. Of greatest significance to
insurers, this article will explore how courts construe ERISA’s state law
preemption language in the context of insurance litigation.
Finally, the article reviews the federal RICO statute, its history,
and the impact of the Humana ruling on a plaintiff’s ability to plead RICO
against insurers. To better understand the potential for increased
RICO litigation against ERISA-governed insurers, the article also examines
recent applications of RICO to claims against life and health insurers.
II.
ERISA and Preemption Law
At the outset, it might be helpful to note that ERISA’s intentionally
sweeping language engenders a great deal of litigation, and often yields
conflicting decisions within the federal court system. (This is ironic,
of course, since ERISA was intended specifically to ensure uniformity of
outcomes.) In early 1997, Justice Scalia noted that since ERISA’s
enactment in 1974, the Supreme Court had decided more than one dozen cases
“to resolve conflicts in the Courts of Appeals regarding ERISA preemption
of various sorts of state law.”[3] By late 1999, the Supreme Court
had decided at least a half-dozen more ERISA preemption cases, and stood
poised to review yet another.
As one expert observes, “ERISA is ‘an enormously complex and detailed
statute,’ but even so, it does not regulate every aspect of employee benefit
plans. Congress anticipated that a regulatory gap would occur and authorized
courts to develop ‘a body of Federal substantive law’ to fill the gaps.”[4]
A review of the history and intent behind ERISA and its broad preemption
provision may help explain why ERISA invites so much litigation against
the insurance industry.
A. Legislative History and Intent
More than a quarter century ago, Congress enacted comprehensive legislation
designed to offer federal protection to employees who participate in employee
benefit plans; this legislation is known as the Employee Retirement Income
Security Act (or ERISA).[5] The intent of ERISA was to protect employee
benefit plan participants and their beneficiaries, “[b]y requiring the
disclosure and reporting to participants and beneficiaries of financial
and other information with respect thereto, by establishing standards of
conduct, responsibility, and obligation for fiduciaries of employee benefit
plans, and by providing for appropriate remedies, sanctions, and ready
access to Federal courts.”[6]
In enacting ERISA, Congress’ primary concern was with the mismanagement
of funds accumulated to finance employee benefits and the failure to pay
employees benefits from the accumulated funds. To that end, it established
extensive reporting, disclosure, and fiduciary duty requirements to insure
against the possibility that the employee’s expectation of the benefit
would be defeated through poor management by the plan administrator. .
. .[7]
Congress intended ‘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 burdens 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’
. . . Therefore, “[t]he basic thrust of . . . [ERISA’s] preemption clause
. . . was to avoid a multiplicity of regulation in order to permit the
nationally uniform administration of employee benefit plans.”[8]
Congress drafted many ERISA provisions in broad terms, intending for
courts to develop a federal common law of employee benefits. By directing
the courts to develop a federal common law addressing rights and obligations
under ERISA plans, Congress hoped to avoid “the threat of conflicting or
inconsistent state and local regulation, . . . laws hastily contrived to
deal with some particular aspect of private welfare and pension plans.”[9]
The decision to provide limited remedies and forms of relief under ERISA
emanated from a desire to balance the competing interests of participants
and of potential employer-sponsors.
Congress intended to provide ERISA plan participants with meaningful
protections against plan abuses, yet Congress found it important to “avoid
creating liability rules that would discourage employers either from establishing
benefits plans, or [from] offering benefits that are stingy and of little
value.”[10] The intentionally broad sweep of ERISA has resulted in
a great deal of complex litigation, some of which will be explored below.
For purposes of this article, one of the most significant elements of the
ERISA legislation is the breadth of state law preemption included under
Section 514. Of greater significance is the judicial interpretation
of this language when extended to life and health insurance plans under
ERISA.[11]
B. Scope of ERISA Law: Defining an ERISA-Qualified Plan
Recently, one ERISA expert characterized the developing federal common
law under ERISA as “the most significant and widespread change in the law
of life, health, and disability benefits litigation.”[12] One reason for
ERISA’s powerful influence may be its sheer pervasiveness: in 1998,
more than 125 million individuals belonged to an ERISA-qualified health
plan,[13] and millions more belonged to ERISA-qualified retirement plans.
Indeed, the broad interpretation given ERISA by federal courts means
that the statute today extends to most employees receiving insurance benefits
through an employer. Recent surveys indicate that as many as 75%
of all managed care plans are ERISA-qualified.[14] Moreover, ERISA
covers millions of other Americans whose benefit plans are established
or maintained by employee organizations which represent employees who are
either engaged in commerce or in any industry or activity affecting commerce.[15]
Controversy surrounds the breadth of ERISA’s statutory language, as
Americans increasingly discover that ERISA covers litigation involving
claims under an employer-sponsored life, health, or disability policy.
In part, coverage results because creating an ERISA-qualified plan is not
difficult. Indeed, some cases indicate that creation of an ERISA
plan was inadvertent. In Parrino v. FHP Inc., for example, the plaintiff-participant
brought numerous state law claims after his group health policy denied
coverage of an experimental brain tumor treatment. In finding the
claims preempted under ERISA, the Ninth Circuit explained that an employer
can establish an ERISA plan, “even if an employer does no more than arrange
for a ‘group-type insurance program’ . . . unless [the employer] is a mere
advertiser who makes no contributions on behalf of its employees.”[16]
As a matter of law, courts generally will find an ERISA plan “if from
the surrounding circumstances a reasonable person can ascertain the intended
benefits, a class of beneficiaries, the source of financing, and procedures
for receiving benefits.”[17] When setting forth a test to determine
whether a plan would qualify as an ERISA-qualified “employee welfare benefit
plan,” the Fifth Circuit Court of Appeals suggested that a plan must meet
the following criteria: (1) the plan must exist; (2) the plan must
comply with the Department of Labor’s safe-harbor provision; and (3) the
plan must satisfy “the primary elements of an ERISA ‘employee benefit plan’—establishment
or maintenance by an employer intending to benefit employees.”[18]
One final criterion requires that an employer must establish and maintain
an “‘ongoing administrative program.’”[19]
Under section 3, a court may conclude that a plan is an ERISA welfare
benefit plan only after finding five prerequisites: “[1] a plan,
fund, or program must be [2] established or maintained [3] by an employer
or by an employee organization, or by both, . . . [4] for the purpose of
providing [an enumerated benefit] [5] [to a participant or beneficiary.]”[20]
As noted, ERISA requires that plans be “established or maintained by an
employer or . . . employee organization.”[21] Courts have construed
this language to require “‘that the plan is part of an employment relationship
. . . [This] requirement seeks to ascertain whether the plan is part of
an employment relationship by looking at the degree of participation by
the employer in the establishment or maintenance of the plan.’”[22]
That same federal court further explained that:
[This test] is designed to distinguish situations in which the employer
merely acts as a conduit for the marketing of an insurance policy to individual
employees (in which case no ERISA plan exists), from the situation in which
the employer financially pays for some or all of the plan and/or is otherwise
involved in its administration (e.g., defining and administering employee
eligibility, or listing the plan as a benefit of employment).[23]
Consequently, merely purchasing insurance for employees will not qualify
a health insurance plan for ERISA if the employer does not directly own,
control, administer, or assume responsibility for the policy or the benefits
provided under the plan.[24]
Similarly, no ERISA plan is established if an employer’s sole involvement
in the benefit plan involves: (1) permitting several life insurance companies
to present plan options to employees, and (2) collecting the plan contributions
and remitting the payments to the various life insurers chosen by the employees.[25]
So long as the insurer establishes and maintains the plans, rather than
the employer, it will not avail the plaintiff to plead “that the [insurer’s]
plan was covered by ERISA because the employer ‘entered into what may be
called an enabling contract’ . . .”[26] This conclusion is reached
because the employer’s activities described above represent only “minimal,
ministerial activities.”[27]
Applying this rule to a suit in which the plaintiff health insurers
alleged that ERISA preempted the insurance commissioner from enforcing
the Texas Healthcare Liability Act, the district court concluded:
The health plans provided by health insurance carriers, health maintenance
organizations, or managed care entities . . . and the health care entities
themselves cannot constitute ERISA plans because the third inquiry under
the Fifth Circuit’s test—whether the plan satisfies the primary elements
of an ERISA ‘employee benefits plan’—must be answered in the negative.[28]
The court found that, while ERISA-qualified plans in fact purchased
health insurance coverage from the plaintiff insurers, the insurers themselves
were not employers capable of establishing or maintaining an ERISA plan.
In other words, because the benefit conferred under an ERISA plan is the
provision of health insurance, and not health care, an insurer who provides
a policy to cover health care cannot supply the plan benefit directly;
only the employer may do so under ERISA.
Congress arguably has provided ERISA with a comprehensive reach by fashioning
the statute to include all employers “engaged in commerce or any industry
or activity affecting commerce.”[29] Courts construe this phrase to indicate
a congressional intent to extend the scope of ERISA as far as the commerce
clause allows.[30] Thus, any employer or employee organization whose
work touches upon interstate commerce could be deemed to fall within the
broad sweep of ERISA.
Yet another indication of congressional intent to give ERISA a broad
reach may be found in the language by which the term “employee benefit
plans” has been defined. Under ERISA, this term includes employer
(or employee organization) programs which provide participants or their
beneficiaries with “medical, surgical, or hospital care, or benefits in
the event of sickness, accident, disability, death,” or unemployment, either
through the purchase of insurance or through some other means.[31]
Consistent with congressional intent, courts have interpreted ERISA
broadly when pleadings implicate insurance benefits. One author suggests
using the following four-part test to decide whether ERISA governs a particular
piece of insurance litigation. That test requires a determination:
“(1) whether the insurance coverage is provided as part of an ‘employee
benefit plan’; (2) whether the plan is established or maintained by an
‘employer’; (3) whether the employer is engaged in ‘commerce’ or
in any ‘industry or activity affecting commerce’; and (4) whether
the plan is a ‘governmental’ plan or a ‘church’ plan.”[32] This final
question is important because an affirmative answer would remove the plan
from ERISA’s reach.[33]
C. Preemptive Powers under ERISA
Perhaps the greatest extension of ERISA’s scope derives from the vast
preemptive authority Congress included in the legislation. Characterized
as “deliberately expansive,”[34] ERISA attempts to create uniform employee
benefit plan laws by broadly preempting state laws[35] that relate to employee
benefit plans.[36] “A law ‘relates to’ a covered employee benefit
plan if it has: (1) a connection with or (2) a reference to such
a plan.”[37]
A California district court has noted that, “[e]arly on in defining
the scope of ERISA preemption, the key statutory phrase ‘relate[s] to’
was given its broad, common sense meaning such that a state law was held
to relate to an ERISA Plan if it ‘had a connection with or reference to
such a plan.’”[38] This expansive reading was difficult to administer,
however, and the Supreme Court subsequently narrowed the preemptive power
of ERISA in cases where state law merely affected the cost of insurance
held in an ERISA plan, or where the wrong-doing occurred prior to actual
formation of the plan (as when an agent wrongfully induces a plaintiff
to buy into an ERISA plan through deceptive sales practices).[39]
However simple the preemption test was intended to be, Justice Scalia
concludes that “. . . applying the ‘relate to’ provision according to its
terms was a project doomed to failure, since, as many a curbstone philosopher
has observed, everything is related to everything else.”[40] When
asked to determine whether California's prevailing wage statute related
to an employee welfare benefit plan within the meaning of ERISA's preemption
clause, the Supreme Court remarked:
Since shortly after its enactment, we have endeavored with some regularity
to interpret and apply the “unhelpful text” of ERISA’s pre-emption provision.
We have long acknowledged that ERISA's pre-emption provision is “clearly
expansive.” It has: “a ‘broad scope,’ and an ‘expansive sweep,’ and . .
. it is ‘broadly worded,’ ‘deliberately expansive,’ and ‘conspicuous for
its breadth.’”[41]
Often, this breadth means that tests for relatedness between a state
law and ERISA will be inconclusive, requiring the courts to examine congressional
intent and the effect of state law upon ERISA plans.[42]
Under the “relate[s] to” test, if a court finds that a plaintiff’s state
law claim depends upon a plan’s existence, ERISA preemption may be triggered.[43]
For instance, after a health insurer denied coverage of an ERISA participant’s
surgical expenses, the plaintiff commenced a state law bad faith and breach
of contract action. However, the claims were held to be preempted under
ERISA, because plaintiff “must necessarily plead and the court must find
that the Plan, governed by ERISA, existed and that [the insurer], in bad
faith, breached the Plan’s terms in denying [Plaintiff] coverage.”[44]
In an extensive review of the Supreme Court’s treatment of ERISA’s language,
a California federal court found that ERISA had “broad and sweeping” preemptive
power over any state law related to covered benefit plans.[45]
The exact language that creates these broad, sweeping preemptive powers
is set forth below:[46]
Except as provided in subsection (b) of this section [the saving clause],
the provisions of this subchapter and subchapter III of this chapter shall
supersede any and all State laws insofar as they may now or hereafter relate
to any employee benefit plan . . . § 514(a), as set forth in 29 U.S.C.
§ 1144(a) (preemption clause).
Except as provided in subparagraph (B) [the deemer clause], nothing
in this subchapter shall be construed to exempt or relieve any person from
any law of any State which regulates insurance, banking or securities.
§ 514(b)(2)(A), as set forth in 29 U.S.C. § 1144(b)(2)(A) (saving
clause).
Neither an employee benefit plan . . . nor any trust established under
such a plan, shall be deemed to be an insurance company or other insurer,
bank, trust company, or investment company or to be engaged in the business
of insurance or banking for purposes of any law of any State purporting
to regulate insurance companies, insurance contracts, banks, trust companies,
or investment companies. § 514(b)(2)(B), 29 U.S.C. § 1144(b)(2)(B)
(deemer clause).[47]
In essence, these provisions are designed to ensure that state laws
relating to employee benefit plans will be preempted by ERISA, unless such
laws regulate the business of insurance (though the deemer clause demonstrates
that Congress was wary of state attempts to skirt preemption by labeling
employee benefit plans ‘insurance companies’). Traditionally, regulation
of the business of insurance has been the sole province of the states under
McCarran-Ferguson.[48] Consequently, if a plaintiff’s action implicates
only the sale of insurance products to be used in an ERISA plan, courts
are content to relegate such conduct to state regulation.
The decision not to preempt state law often implies a significant policy
consideration: under ERISA, there would be no remedy for the plaintiff
in a wrongful inducement suit, since there would be no benefit denial.
ERISA preemption thus would have “the effect of allowing fraud by benefit
plan marketers to go unchecked. This would be an odd result for legislation
designed to protect the rights of employees and to encourage the creation
of benefit plans.”[49]
Only in cases where an agent’s misconduct relates to the plan will ERISA’s
civil enforcement scheme preempt state remedies.[50] Consequently, ERISA
will not preempt state law fraud claims when the fraudulent conduct was
independent of the benefit plan. Therefore, the misrepresentations
may not relate to the plan itself or to benefits due under the plan.[51]
Yet for each exception, there appear to be any number of state laws that
are preempted.
Typical state laws subject to ERISA preemption include “common law claims
based on breach of contract, breach of tort duties, fraud, estoppel, bad
faith, or statutory violations . . . if the claims ‘relate to’ benefits
provided under an employee benefit plan.”[52] Just as state laws
may be preempted, so may common law rules of contract interpretation.
Thus, in an ERISA suit, there is no place for state law principles requiring
contracts to be strictly construed against an insurer, or other principles
requiring that contracts comply with an insured’s reasonable expectations.[53]
Exclusion of these principles helps maintain uniformity in federal ERISA
law. Other state laws are likely to be preempted under ERISA as well.
These include: “‘state laws providing alternative enforcement mechanisms’”
for ERISA plan benefits, as well as “state laws that mandate[ ] employee
benefit structures or their administration . . . [and] state causes of
action based on alleged improper handling of claims for medical benefits
under an ERISA plan.”[54]
Courts have established some limits on ERISA’s scope, however.
While ERISA’s expansive preemptive language enables it to “supersede any
and all [s]tate laws insofar as they may now or hereafter relate to any
employee benefit plan,”[55] courts have determined that “some state actions
may affect employee benefit plans in too tenuous, remote, or peripheral
a manner to warrant a finding that the law ‘relates to’ the plan.”[56]
Consequently, ERISA does not preempt state laws which have “only an indirect
economic effect on the relative costs of various health insurance packages”[57]
available to ERISA-qualified plans.
Guided by congressional intent and by ERISA’s emphasis on providing
uniform federal protection of employee benefits, courts are most likely
to preempt state law when a plan participant or the participant’s beneficiary
alleges wrongful denial of benefits due under an ERISA plan. “A claim
based on state law is more likely to relate to an ERISA plan if it falls
within an area of exclusive federal concern and directly affects the relationship
between the principal entities (the employer, the plan, the fiduciaries,
and the participants and beneficiaries).”[58] Thus, if a plaintiff-plan
participant alleges that the ERISA-qualified HMO failed to treat a condition
as the result of a benefits determination, the claim will be preempted.
However, if the plaintiff-plan participant sues an HMO for breaching
the standard of care for the health care benefit delivered, some courts
will find no preemption. In such cases, the “[p]laintiff’s allegations
are not based upon any mishandling or denial of claims under the health
benefit plan, but rather are based upon the quality of care which [was]
received. ‘A claim about the quality of a benefit received is not
a claim . . . to recover benefits due . . . under the terms of the plan.’”[59]
Courts recently have been asked to apply this distinction to a growing
number of suits against ERISA-qualified HMO plans, in which the plaintiffs
allege that cost-saving measures resulted in injury.[60] As discussed
later, one of these cases was decided recently by the Supreme Court.[61]
Claims have been lodged under various tort doctrines, contractual theories,
commercial bribery statutes, deceptive trade practices acts, racketeering
statutes, extortion, breach of fiduciary duties, and agency theories.
However, so long as the claim focuses on denial of benefits, courts are
apt to find the state law claim preempted under ERISA, since ERISA
preemption is implicated when a plaintiff’s pleadings concern benefit determinations
made under the plan. Such a situation exists, for example, when “the
HMO [makes] medical decisions due to a cost containment feature of the
plan and thus ‘implicate[s] the management of plan assets.’”[62]
In at least one other recent case regarding the denial of certain medical
treatments under a health insurance plan, the Fifth Circuit has similarly
held, and other circuits have also held that claims regarding plan guidelines
and utilization review procedures are preempted . . . In the instant case,
Plaintiffs allege that Silva’s death resulted from Kaiser’s decisions and
restrictions concerning plan benefits. . . These assertions amount to a
claim for denial of ERISA plan benefits; therefore, Plaintiffs’ claims
against Kaiser are preempted by ERISA.[63]
For many, the recent trend toward recognizing causes of action against
HMOs for vicarious liability, respondeat superior, and medical negligence
offers promise. Since these theories do not implicate the administration
of benefits, plaintiffs may be able to avoid ERISA preemption problems.
Nevertheless, ERISA’s broad preemptive powers remain a daunting hurdle
for many litigants who wish to bring state law claims against qualified
insurance plans.[64]
D. ERISA’s Enforcement Provisions
It is important to note that preemption of a state law claim will not
leave an ERISA participant or beneficiary entirely without recourse.
Under Section 1132, the participant may bring an action for benefits, allowing
him “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 . . .”[65] Remedies are limited to
those enumerated in the statute, and courts have construed this limitation
strictly.
In one such case, Massachusetts Mutual Life Ins. Co. v. Russell, the
Supreme Court held that a participant who brought suit alleging breach
of fiduciary duty under ERISA was not eligible for extra-contractual compensatory
or punitive damages.[66] “Several courts . . . have interpreted the
decision in Russell, broadly, and have held that extra-contractual compensatory
or punitive damages are not available in any ERISA action, including an
action brought by a participant for benefits due under the terms of the
plan.”[67]
One consequence of the scant relief available under ERISA is that some
courts have been frustrated in their efforts to assign a remedy:
“‘Under traditional notions of justice, the harms alleged—if true—should
entitle [the plaintiff] to some legal remedy.’ ERISA, however, does
not always vindicate traditional notions of justice, either for the plan
or for its participants.”[68] Additionally, because most courts view ERISA
actions as equitable in nature, the parties have no right to a trial by
jury.[69]
In fact, before a claimant can even be heard in court, he or she must
first contend with the congressional mechanism for abating ERISA suits:
administrative review under Section 503. All plans formed under ERISA
must establish and maintain administrative procedures (and remedies) for
handling benefit claims made by plan participants and beneficiaries.[70]
Should a participant fail to seek such review in a timely fashion, courts
are likely to deny the claimant any right to be heard.[71] Furthermore,
“[w]hile the statute is silent with respect to whether participants are
required to exhaust their administrative remedies before seeking relief
in the courts, the federal courts of appeal unanimously have held that
a participant must exhaust whatever avenues of administrative review exist
under the plan before commencing a legal action challenging a denial of
benefits.”[72]
This strict application of the “exhaustion requirement” is designed
not only to reduce the number of claims brought under ERISA, but also to
improve consistency in disposition, to minimize settlement costs, and to
provide an alternative dispute-resolution methodology.[73] Notwithstanding
the importance of these goals, however, courts acknowledge that administrative
review is not always feasible and have carved out four exceptions to the
exhaustion requirement:
1. FUTILITY: Construed narrowly,
the test is whether the claimant had an opportunity to avail himself of
a review—not whether his claim would have succeeded. The standard
is “a clear and positive showing of futility.”
2. ACCESS DENIED: Here, a claimant
must demonstrate that he tried to access the review procedure, but was
denied meaningful access by those controlling the review process.
3. IRREPARABLE HARM: Rarely used,
this requires a claimant to establish that judicial review is necessary
to avoid irreparable harm to his career or to his ability to exercise his
rights under the plan.
4. NOTICE FAILURE: In one district
court case, a plan’s deficient denial letter so failed to give the participant
notice that the court held the claimant was excused from employing administrative
remedies. “However, most courts hold that deficiencies in the denial
letter do not absolve a claimant from exhausting administrative remedies;”
they only toll the time considered reasonable for seeking review.[74]
III.
Litigation Alleging Violation of ERISA Fiduciary Duties
One final area of ERISA litigation that affects insurers, especially
as it relates to RICO claims, involves the alleged breach of fiduciary
duty. Title I of ERISA both delineates general standards of conduct
for plan fiduciaries and disallows certain transactions.[75] The
section also requires that every plan designate one named fiduciary who
bears responsibility for operating and administering the plan.[76]
However, fiduciary status is not determined solely by designation.
Courts also may apply ERISA’s characteristically broad functional test
to conclude that an undesignated person is a plan fiduciary, to the extent
the person:
(i)
exercises any discretionary authority or control with respect to management
of the plan,
(ii)
exercises any authority or control (whether or not discretionary) concerning
management or disposition of the plan’s assets,
(iii)
renders investment advice concerning plan assets for which he receives
direct or indirect compensation, or
(iv)
has any discretionary authority or responsibility for administration of
the plan.[77]
Due to the breadth of this functional definition (which far exceeds
traditional trust law concepts of fiduciary status), a plan might have
many fiduciaries, including trustees, investment committee members, the
Board of Directors (or any group charged with selecting the investment
committee), investment advisors, and “all individuals active in the administration
of the plan who have discretionary authority.”[78]
Indeed, the definition is broad enough to justify the characterization
that, “under ERISA, the persons with the ultimate responsibility to determine
whether a benefits plan will cover a claim are cloaked with fiduciary status.”[79]
Consequently, a plan is likely to have multiple fiduciaries, though each
one’s duties will extend only to those aspects of the plans over which
the person exercises authority or control.[80]
These rules generally mean that ERISA codifies an expanded version of
the common law definition of fiduciary duty. Nevertheless, courts
tend to consider this expansion in light of “the special nature of employee
benefit plans” when defining an ERISA fiduciary’s duties.[81] This
viewpoint generally results in an evolving definition of duties which commentators
characterize as strict.[82] The duties an ERISA fiduciary owes to
the plan include:
(i)
THE DUTY OF LOYALTY: Discharge duties solely in the interest of plan participants
and their beneficiaries exclusively for the purpose of efficiently providing
benefits to these individuals.
(ii)
THE DUTY OF PRUDENCE: Act “with the care, skill, prudence, and diligence
under the circumstances then prevailing that a prudent man acting in like
capacity and familiar with such matters would use in the conduct of an
enterprise of a like character and with like aims.” This “prudent
expert” rule often sets a higher standard than state trust law.
(iii)
THE DUTY TO ACT IN ACCORDANCE WITH THE PLAN’S GOVERNING DOCUMENTS:
However, fiduciaries must ensure there is no conflict between these documents
and ERISA, because if ERISA provisions conflict with these instruments,
ERISA controls.
(iv)
THE DUTY TO MONITOR THOSE TO WHOM FIDUCIARY RESPONSIBILITIES WERE DELEGATED:
Delegate only if the plan explicitly allows it and describes the procedure
for delegation. Fiduciaries who delegate responsibility must monitor
the delegate’s conduct and will remain jointly and severally liable. [83]
It should be noted that breach of a fiduciary duty may result in personal
liability, requiring the fiduciary to “make good to the plan, any loss
incurred by reason of his breach. Additionally, such a fiduciary
must ‘restore to such plan’ any profits made by him through the improper
use of plan assets.”[84] Though punitive and extracontractual damages
are generally unavailable, injunction, removal, and other forms of equitable
relief may be granted against the breaching parties.[85]
A. Herdrich: A Challenge for the Supreme Court
Plaintiffs increasingly are bringing suit against HMOs that have sold
policies to ERISA-qualified plans, alleging that the HMO’s cost-containment
methods violate ERISA’s fiduciary duties. In one recent Supreme Court
case, the plaintiffs alleged that their HMO breached its fiduciary duty
to ERISA plan participants by employing typical HMO cost-control measures.
These efforts at cost containment allegedly violated ERISA fiduciary duties
because they were not “solely in the interest of participants and beneficiaries.”[86]
In a two-to-one decision, hotly contested on motion for rehearing, the
Seventh Circuit Court of Appeals determined that HMO cost-containment measures
violated ERISA.[87] “A fiduciary breaches its duty of care under
section 1104(a)(1)(A) whenever it acts to benefit its own interests . .
. The requirement that an ERISA fiduciary act ‘with an eye single to the
interest of the participants and beneficiaries,’ is the most fundamental
of his or her duties, and must be enforced with uncompromising rigidity.”[88]
Likewise, in language criticized by the dissent, the court remarked: “with
a jaundiced eye focused firmly on year-end bonuses, it is not unrealistic
to assume that doctors rendering care under the Plan were swayed to be
most frugal when exercising their discretionary authority to the detriment
of their membership.”[89] Thus, the court concluded that HMO cost-saving
incentives may rise to the level of a breach if the court suspects that
doctors have delayed necessary care for “the sole purpose of increasing
their bonuses.”[90]
In a unanimous decision reversing the Seventh Circuit Court of Appeals,
however, the United States Supreme Court determined that an HMO, whose
plan was part of an employer’s ERISA benefits package, did not qualify
as a plan fiduciary to the extent that such an HMO (acting through its
physicians) made mixed eligibility and treatment decisions. The Seventh
Circuit had concluded that when an HMO’s Board of Directors is also composed
of the doctors who make the benefit determinations, there is a sufficient
level of “discretionary control and authority” over plan assets to justify
imposition of ERISA fiduciary duties on the HMO. The court found
particularly compelling plaintiffs’ allegation that their HMO retained
“the exclusive right to decide all disputed and non-routine claims under
the plan.”[91]
On the other hand, the dissenting members of the Seventh Circuit had
made an equally compelling argument against the decision. Judge Easterbrook
argued that an HMO could not retain the requisite discretion “in the administration
of the plan;” discretion could only lie in the provision of medical services:
Perhaps this issue boils down to a matter of characterization.
If one conceives of particular medical services as the “benefits” under
the plan, then Carle [the defendant HMO] serves as the gatekeeper to those
benefits, and handling claims for medical benefits defined by a plan is
a fiduciary role under ERISA. But if instead one conceives of the CarleCare
HMO system as the benefit promised by the ERISA plan, then Carle is not
a “fiduciary.” It is just the supplier of medical care . . . [T]o
the extent there is uncertainty about the right way to characterize Carle’s
role, the court should . . . [treat] the Carle HMO as the benefit, rather
than treating Carle as the administrator of the ERISA plan. If the
HMO system is the benefit, then Carle is not acting as a fiduciary. [92]
Dissecting the policy implications of the majority’s opinion, the dissent
explained:
The choice between these characterizations is important . . . Most medical
care these days is furnished under ERISA plans. Most contemporary
welfare benefit plans provide for managed care, through HMOs or other devices,
at least as an option. The panel’s opinion thus implies that the
principal organizational forms through which medical care is delivered
today are unlawful. If this conclusion is correct, then the cost?saving
achieved by managed care must be abandoned, and the cost of medical care
will rise, perhaps substantially. [93]
This subtlety has been largely ignored by lower courts in cases addressing
HMO fiduciary status under ERISA, but it was not ignored by the United
States Supreme Court. In fact, the subtlety was enhanced.
Traditionally, once a court found that a health insurer administered
benefits or retained discretionary control or authority to make benefits
determinations, the court declared the insurer a fiduciary.[94] In
Weiss v. Cigna Healthcare, the New York district court summarily concluded
that an HMO properly could be deemed an ERISA fiduciary when it exercises
discretionary power in management or administration.[95] Thus, to
the extent the HMO “exercises discretionary control over the communication
of medical information to Plan participants,” imposing a “gag order” on
HMO physicians would be a fiduciary breach.[96] In contrast to the Seventh
Circuit’s Herdrich decision, however, the Weiss court found that no fiduciary
duty is breached when an HMO offers financial incentives to physicians
as part of a cost-control measure.[97] The distinguishing feature
between the two decisions might be that the Herdrich HMO doctors were also
the owner-operators of the defendant HMO, while Weiss’ HMO doctors were
more independent. As the Weiss court explains, “[t]he profit motive
created by the HMO does not make [violations of the ERISA fiduciary duty]
‘inevitable.’”[98]
In
a more detailed finding of fiduciary status, the New Hampshire district
court concluded that because an HMO in an ERISA plan has discretionary
control and authority over the plan (in part because the HMO has the right
to exercise final control over benefit appeals), “it plainly qualifies
as a fiduciary under ERISA.”[99] The court relied in part on precedent,
stating that a benefits determination under the terms of plan documents
is a fiduciary act.[100] The court also cited relevant language:
“When an insurance company administers claims for [a plan] and has authority
to grant or deny the claims, the company is an ERISA ‘fiduciary’ . . .
."[101]
When
analyzing this same issue of fiduciary status in Herdrich, the United States
Supreme Court first defined a “plan” within the meaning of ERISA.
Utilizing a broad definition derived from common understanding, the Court
defined an ERISA plan as a “scheme decided upon in advance.”[102]
The Court then described the structure of an HMO scheme or “plan:”
Here
the scheme comprises a set of rules that define the rights of a beneficiary
and provide for their enforcement. Rules governing collection of
premiums, definition of benefits, submission of claims, and resolution
of disagreements over entitlement to services are the sorts of provisions
that constitute a plan . . . Thus, when employers contract with an HMO
to provide benefits to employees subject to ERISA, the provisions of documents
that set up the HMO are not, as such, an ERISA plan, but the agreements
between an HMO and an employer who pays the premiums may, as here, provide
elements of a plan by setting out rules under which beneficiaries will
be entitled to care.[103]
Moreover, since fiduciary obligations can apply to managing, advising
and administering an ERISA plan, the HMO may be a fiduciary if it administers
the plan, notwithstanding its status when it administers or exercises discretionary
authority over its own business.
Having made that determination, the Supreme Court acknowledged that
an ERISA fiduciary is not entirely governed by the common law of trusts,
as noted earlier. At this juncture, however, the Supreme Court drew
a critical distinction. Whereas the common law trustee acts as fiduciary
whenever that trustee takes action to affect a beneficiary, the ERISA fiduciary
may act in different capacities with respect to its beneficiaries, only
some of which carry traditional fiduciary responsibilities. For example,
an ERISA fiduciary may have financial interests adverse to plan beneficiaries.
Specifically, employers can be ERISA fiduciaries and still act to the disadvantage
of employee beneficiaries when they act as employers or plan sponsors.[104]
Notwithstanding this distinction, ERISA does require that the ERISA fiduciary
wear “only one [hat] at a time, and wear the fiduciary hat when making
fiduciary decisions.”[105] Thus, a plan administrator is an ERISA fiduciary
“only ‘to the extent’ that he acts in such a capacity in relation to a
plan.”[106] In that context, the threshold question must be whether
the plan administrator “was acting in a fiduciary (that is, was performing
a fiduciary function) when taking the action subject to complaint.”[107]
Given the specific breach of duty alleged by Ms. Herdrich, the Supreme
Court observed that there was no ERISA violation when incorporators of
the Carle HMO provided for a year-end payment to physicians, since the
HMO was not the ERISA plan and the incorporation of the HMO preceded the
HMO contract with the employer’s plan. The pivotal issue thus concerned
whether the Carle HMO became a plan fiduciary, acting through its physicians,
when Carle contracted with the employer. When deciding this issue,
however, the Court noted that it was important to further distinguish between
two administrative acts: “eligibility decisions” (those turning on the
plan’s coverage of a particular condition or medical procedure) and “treatment
decisions” (choices about how to diagnose and treat a patient’s condition).[108]
Although Congress arguably intended that fiduciary status would extend
to eligibility decisions about managing assets and distributing property
to beneficiaries, it did not intend Carle or any other HMO to be treated
as a fiduciary to the extent it makes mixed eligibility and treatment decisions,
e.g., “physicians’ conclusions about when to use diagnostic tests; about
seeking consultations and making referrals to physicians and facilities
other than Carle’s; about proper standards of care, the experimental character
of a proposed course of treatment, the reasonableness of a certain treatment,
and the emergency character of a medical condition.”[109] The power
to reform HMOs lies with Congress and not the federal judiciary. Borrowing
the rationale of the Seventh Circuit dissent in Herdrich, the Supreme Court
remarked that “the Federal Judiciary would be acting contrary to the congressional
policy of allowing HMO organizations if it were to entertain an ERISA fiduciary
claim portending wholesale attacks on existing HMOs solely because of their
structure, untethered to claims on concrete harm.”[110] At least
in this respect, plaintiffs’ lawyers have been unable to achieve through
the courts what Congress allegedly has failed to do through legislation:
reform the HMOs.[111]
IV.
RICO: The Racketeer Influenced and Corrupt Organizations Act
Having thus reviewed the breadth of ERISA’s coverage, it is not surprising
that those familiar with this area of law might consider ERISA litigation
to be among the most significant and far-reaching forces in life, health
and disability benefits litigation. However, another federal law
has begun to assert a growing influence on the insurance industry—the Racketeer
Influenced and Corrupt Organizations Act (RICO). Since 1985, more
than forty-five lawsuits alleging that an insurer breached both ERISA and
RICO have been heard in the nation’s federal courts.[112] Unfortunately
for the insurance industry, RICO claims are likely to increase as a result
of the Supreme Court’s recent pronouncement in Humana v. Forsyth.[113]
In a departure from precedent, the Court decided to construe McCarran-Ferguson’s
preemptive authority narrowly, based on a finding that RICO provided a
nice complement to state anti-fraud measures against the insurers.
Nearly one decade ago, a perspicacious attorney predicted that RICO
claims against insurers would swell, since the Supreme Court had promulgated
a ruling effectively lowering the threshold for establishing a RICO claim.[114]
Until the Humana ruling, however, courts remained reticent to apply RICO
to suits against insurers. The 1999 Humana decision changed all that,
removing one of the most effective defenses to RICO from the insurers’
armory. As a result, leading members of the plaintiffs’ bar met late in
1999 to assemble a strategy for suing the nation’s largest health maintenance
organizations under RICO. Shortly thereafter, they began their campaign
by launching a weighty salvo against Aetna on behalf of 18.3 million enrollees.[115]
One aspect of RICO that makes it so attractive to contemporary plaintiffs
is the range of penalties. Though violators face criminal penalties ranging
from imprisonment to fines and forfeitures,[116] that is not what
most interests today’s insurance plaintiffs. Instead, it is the statutory
language allowing private actions: “any person injured in his business
or property by reason of a violation of § 1962 of this Chapter may
sue therefore in any appropriate United States District Court and shall
recover threefold the damages he sustains and the cost of the suit, including
a reasonable attorney’s fee.”[117]
As may be expected, the mandatory treble-damages language (“shall recover”)
makes RICO a popular, if not irresistible, legal theory for many.
Combined with the impressive preemptive power ERISA exerts over a large
number of health and life insurance claims, it is not surprising that RICO’s
popularity would grow. Furthermore, within the insurance context,
the fact that RICO is not a state law subject to ERISA preemption makes
it a useful tool for plaintiffs facing such a limitation.
A. Legislative History and Intent
Congress enacted the Racketeer Influenced and Corrupt Organizations
Act (known as RICO) nearly thirty years ago, as part of the Organized Crime
Control Act of 1970. Though many RICO defendants have attempted to
argue that the statute should be read narrowly to address only “organized
crime,” the Supreme Court has rejected this line of argument. [118]
Instead, the Court has relied on RICO’s legislative history to conclude:
that even though “[t]he occasion for Congress’ action was the perceived
need to combat organized crime, . . . Congress for cogent reasons chose
to enact a more general statute, one which, although it had organized crime
as its focus, was not limited in application to organized crime.”[119]
Summarizing its review of RICO’s legislative history, the Court emhasized
the heavy ammunition Congress intended to level at all types of organized
crime:
The federal RICO statute was passed to eradicate the infiltration of
legitimate business by organized crime. Earlier steps to combat organized
crime were not successful, in large part because traditional penalties
targeted individuals engaged in racketeering activity rather than the criminal
enterprise itself. Punishing racketeers with fines and jail terms failed
to break the cycle of racketeering activity because the criminal enterprises
had the resources to replace convicted racketeers with new recruits. In
passing RICO, Congress adopted a new approach aimed at the economic roots
of organized crime: “What is needed here . . . are new approaches that
will deal not only with individuals, but also with the economic base through
which those individuals constitute such a serious threat to the economic
well-being of the Nation. In short, an attack must be made on their source
of economic power itself, and the attack must take place on all available
fronts.” Criminal liability under RICO is premised on the commission of
a “pattern of racketeering activity,” defined by the statute as engaging
in two or more related predicate acts of racketeering within a 10-year
period. A RICO conviction subjects the violator not only to traditional,
though stringent, criminal fines and prison terms, but also mandatory forfeiture
under § 1963.[120]
Though racketeering is apt to evoke images of gangster activity for
many, in truth, RICO “has become a favorite – and lucrative – weapon of
attorneys who claim health insurance providers are ripping off their policyholders.”[121]
Indeed, the Supreme Court has acknowledged that many legitimate businesses
are subject to RICO:
It is true that private civil actions under the statute are being brought
almost solely against [respected businesses], rather than against the archetypal,
intimidating mobster. Yet this defect—if defect it is—is inherent in the
statute as written and its correction must lie with Congress. We
nonetheless recognize that, in its private civil version, RICO is evolving
into something quite different from the original conception of its enactors.[122]
Such an evolution is due largely to the rather expansive definition
afforded to the term, “racketeering.”
B. Applying RICO
As defined under RICO, racketeering involves “any act ‘chargeable’ under
several generically described state criminal laws, and any act ‘indictable’
under numerous specific federal criminal provisions including mail and
wire fraud . . .”[123] Within the general classes of crimes enumerated
in 18 U.S.C. §1961(1), there is no specific mention of insurance practices.[124]
However, courts consistently find that various other provisions of the
statute support actions both by and against insurers.
Among the RICO provisions most relevant to the instant inquiry is the
section of RICO styled, “Prohibited Activities.” Under its Prohibited
Activities section, RICO makes it illegal to apply money derived from a
“pattern of racketeering activity” to an enterprise engaged in or affecting
interstate commerce; to acquire or maintain an interest in an enterprise
“through” a pattern of racketeering activities; to conduct or participate
in the conduct of an enterprise through a pattern of racketeering activities;
or to conspire to violate any of the above provisions.[125]
A “pattern of racketeering activity” may be found only if the defendant
engaged in “at least two acts of racketeering activity, one of which occurred
after the effective date of this chapter and the last of which occurred
within ten years (excluding any period of imprisonment) after the commission
of a prior act of racketeering activity.”[126] In insurance litigation,
establishing this “pattern of racketeering activity” often proves a decisive
element in a plaintiff’s claim.
Indeed, to properly state an action under RICO’s civil liabilities section,
plaintiffs “must plead the conduct of an ‘enterprise’ through a pattern
of racketeering activity, as well as injury to the plaintiff, his business
or his property.”[127] As one court has summarized the requisites, “[t]o
state a claim under RICO, the plaintiffs must allege: (1) that a person;
(2) conducted the affairs; (3) of an enterprise; (4) through a pattern
of racketeering activity.”[128] To understand how these requirements
affect RICO litigation against insurers, it is necessary to examine the
requisites of an “enterprise.”
C. RICO Enterprise Defined
Under Section 1962(c), RICO makes it “unlawful for any person employed
by or associated with any enterprise engaged in . . . interstate commerce,
to conduct or participate, directly or indirectly, in the conduct of such
enterprise’s affairs through a pattern of racketeering activity.”[129]
Consequently, a plaintiff’s RICO count will be dismissed if it fails both
“to identify the enterprise and each defendant’s role in the pattern of
racketeering activity.”[130] After all, “it is the existence of an enterprise
that distinguishes a RICO conspiracy from other conspiracies. A RICO
conspiracy claim cannot stand absent an allegation of the involvement of
an enterprise.”[131] As the Seventh Circuit has explained:
[A] prototypical RICO enterprise is a criminal gang not incorporated
under the laws of any state or compliant with the provisions of the Uniform
Partnership Act. But we do not see how the acts complained of in this case
can be thought the work of an organization, however loose-knit. . . . [The
action before us constitutes] a conspiracy, but it is not an enterprise
unless every conspiracy is also an enterprise for RICO purposes, which
the case law denies.[132]
Generally speaking, RICO enterprises must exhibit three characteristics:
“(1) a common or shared purpose; (2) some continuity of structure and personnel;
and (3) an ascertainable structure distinct from that inherent in a pattern
of racketeering.” [133] In light of the perpetual ingenuity of the criminal
mind, however, courts are apt to take an adaptive approach to the definition
of enterprise. Fortunately, even under this approach, some RICO enterprises
are easier to identify than others:
When a “Legal” entity is the enterprise under consideration,
“there is little difficulty in proving the existence of the enterprise.
Proof that the entity in question has a legal existence satisfies the enterprise
element.” In contrast, proving the existence of an association-in-fact
enterprise requires showing that “a group of persons associated together
for a common purpose of engaging in a course of conduct.”[134]
Nevertheless, “a group of persons associated together for a common purpose
of engaging in a course of conduct” may be more difficult to prove than
it sounds, as one plaintiff discovered. When this RICO plaintiff
attempted to show that his insurer participated in an association-in-fact
enterprise, the court noted that RICO required him to demonstrate that
the defendant insurer “participated in the conduct of an enterprise’s affairs
through a pattern of racketeering activity.”[135] In order to establish
the existence of a RICO enterprise, the plaintiff had to allege more than
just the predicate acts. The plaintiff had to show that “the enterprise
[had] an independent structure, separate and apart from the structure inherent
in the conduct of the pattern of racketeering activity.”[136] Thus,
a plaintiff wishing to establish an enterprise must show some connection
between it and the predicate acts:
[A]ll that is required [to delineate between the enterprise and the
predicate acts] is a “nexus” or “connection” between the enterprise and
the racketeering activity in which the activity in some way stems from
the enterprises’ activities or otherwise has some relationship to the enterprise
. . .[A] nexus exists “when (1) one is enabled to commit the predicate
offenses solely by virtue of his position in the enterprise or involvement
in or control over the affairs of the enterprise, or (2) the predicate
offenses are related to the activities of that enterprise.”[137]
Plaintiffs are also likely to encounter difficulty establishing the
existence of an enterprise when their litigation implicates the relationship
between company and agent. Because a corporation cannot conspire
with itself, the issue of whether an agent is a separate person is pivotal,
involving concomitant issues of intracorporate immunity. However,
courts may easily dispense with this argument under the “personal gain”
exception, if they find evidence that either the agent or the insurer had
an individual stake in achieving the illegal objective (e.g., the agent
stood to personally gain through illegally-attained commissions).[138]
Questions of this nature frequently appear in RICO litigation.
In Davis v. Mutual Life Ins. Co. of New York, a policyholder defrauded
by a corrupt life insurance agent sued MONY under RICO.[139] The
jury found that MONY had participated in the agent’s mail and wire fraud,
forming the requisite RICO enterprise.[140] MONY challenged the finding
on the grounds that, “a corporation cannot be both the ‘enterprise’ and
the ‘person’ conducting or participating in the affairs of that enterprise
. . . Under the . . . ‘distinctness’ requirement, a corporation may not
be liable under section 1962(c) for participating in the affairs of an
enterprise that consists only of its own subdivisions, agents, or members.”[141]
However, because the court found that the agent’s fraudulent business was
sufficiently distinct from MONY, and that MONY continued to participate
in the agent’s scheme even after notice of its fraudulent nature, it affirmed
the jury’s findings and allowed RICO liability to attach.[142]
In litigation against HMOs, the problem is similar: how to meet the
distinctness requirement between the insurer and its subsidiaries or affiliated
doctors. Plaintiffs must show that a parent and its subsidiaries
are an “enterprise” if there is an association-in-fact, in which “the defendants
are not distinct from the enterprise.”[143] For example, no RICO enterprise
can exist if Aetna and each of its subsidiary HMO operations is not sufficiently
distinct and separate. Nor may a plaintiff establish an enterprise
between an HMO and its independent doctors when the plaintiff admits that
the doctors and HMO share no common purpose and, indeed, are at odds with
one another.[144] If a plaintiff succeeds in establishing the distinctness
and enterprise requirements, an insurer must be prepared to defend against
allegations that they engaged in a “pattern of racketeering activity.”
D. Pattern of Racketeering Activity Defined
Recognizing the increasing frequency with which attorneys use RICO against
insurers, the Seventh Circuit in one case has remarked: “At last we arrive
at AAP’s RICO claims, which these days seem to be tacked onto securities
and ERISA complaints as a matter of course. They should not be.”[145]
Language of this sort seems apt when a plaintiff is unable to meet RICO’s
requirement that he or she establish a “pattern” of racketeering activity
with “proof of at least two of the felonies the statute specifies as predicate
acts.”[146]
Under RICO, these plaintiffs must allege at least two predicate acts
because RICO is not directed toward isolated offenders; instead, it aims
to punish those who threaten to engage in a continuous criminal enterprise.[147]
Moreover, merely alleging two acts may not be enough to establish the requisite
pattern: “[t]he predicate acts must be sufficiently related to constitute
an ongoing and continued enterprise; but they must also be sufficiently
distinct to comprise a pattern, as opposed to a single fraudulent act perpetrated
in a series of steps.”[148]
To determine whether a defendant’s activities are sufficiently continuous,
courts test the facts alleged against the following factors: the
number of independent victims; the number of participants; the purpose
of the activity; the result of the activity; the method of commission;
the number of transactions; whether the scheme is ongoing and open-ended;
and the duration of the activity.[149] Dismissing a plaintiff’s RICO suit
against an insurer who allegedly dropped small, unprofitable group plans,
one court explained that a proper RICO complaint must allege the requisite
continuity. Without a sufficient showing of continuity, the plaintiff
(who alleged two acts of mail fraud and one act of wire fraud) could not
support a RICO claim.[150] According to the court, a “closed-ended scheme
lasting only a few months” is insufficient under RICO’s “pattern of racketeering
activity” requirement.[151] “Rather, the RICO pattern requires plaintiff
to show ‘that the racketeering predicates are related, and that they amount
to or pose a threat of continued criminal activity.’”[152] Thus, continuity
requires either a “closed period with repeated conduct, or . . . past conduct
that by its nature projects into the future with a threat of repetition.”[153]
[A] party alleging a RICO violation may demonstrate continuity over
a closed period by proving a series of related predicates extending over
a substantial period of time. Predicate acts extending over a few
weeks or months and threatening no future criminal conduct do not satisfy
this requirement: Congress was concerned in RICO with long-term criminal
conduct.[154]
Because mail and wire fraud are commonly the “pattern of racketeering
activity” of choice for plaintiffs suing insurers, it is important to understand
the elements of mail or wire fraud. These elements include: “(1)
a scheme or artifice to defraud, and (2) use of the Postal Service or interstate
wires [e.g., telephone or facsimile] for the purpose of executing the scheme
or artifice.”[155] Both statutes also require a specific intent to
deceive or defraud, though the requirement is met so long as the plaintiff
can demonstrate “the existence of a scheme which was ‘reasonably calculated
to deceive persons of ordinary prudence and comprehension,’ and this intention
is shown by examining the scheme itself.”[156] Once this requirement is
satisfied, the plaintiff’s complaint must plead the predicate acts of mail
or wire fraud with particularity, alleging “the time, place, and specific
content of the false representations as well as the identities and the
parties to the misrepresentation.”[157]
Applying these rules to allegations that a life insurer had violated
RICO by failing to adequately disclose the interest rate risk of a single
premium whole life product, the court upheld dismissal of the RICO claims.[158]
Because the insurance company’s sales literature did not contain “misrepresentations
or omissions reasonably calculated to deceive persons of ordinary prudence
and comprehension,” no scheme and thus no pattern of racketeering was established.[159]
Ultimately, the court found only that the plaintiffs had misinterpreted
the plain meaning of the defendant insurer’s promotional literature --
a misfortune not covered under RICO.
E. Timing: The Statute of Limitations
The statute of limitations is another defense insurers might raise in
a RICO suit. In one such case, plaintiff provided an employee retirement
plan to its employees. Among the group benefits available was one
of the defendant’s fixed annuity contracts.[160] Following a dispute
over the calculation and award of interest credit to the plaintiff’s ERISA-qualified
benefit plan, plaintiff brought suit under ERISA and RICO. Under
the RICO claim, plaintiff alleged that, “‘Defendant’s knowing and intentional
misrepresentations and omissions of material facts’ concerning the reporting
of credited interest and the assessment of the management fee violated
[RICO].”[161]
The principal issue under consideration in this case was the four-year
limitations period. Ultimately, the court determined that, “the near
universal consensus among circuit courts is that the claim accrues from
the time the plaintiff discovered or should have discovered the injury.”
This means that the statute of limitations will not begin to run until
the plaintiff discovered or should have discovered the pattern of racketeering
activity (requiring that she recognize her injury is part of a pattern
of defendant’s behavior).[162]
E. RICO Preemption under McCarran-Ferguson
A new frontier in insurance litigation arose from the Supreme Court’s
decision in Humana v. Forsyth in 1999.[163] Prior to that decision,
insurers successfully argued that RICO claims were preempted under the
McCarran-Ferguson Act.[164] Under this Act, federal legislation affecting
the business of insurance would apply only if it did not “‘invalidate,
impair, or supersede’ the state’s regulation.”[165] McCarran-Ferguson
was enacted by Congress in 1945. It responded to a Supreme Court
decision that, for the first time, declared the business of insurance to
be commerce, subject to federal regulation and to the Sherman Act.[166]
Congress was concerned that the Court’s ruling would undermine state regulatory
efforts, since each state operates a Department of Insurance to regulate
the business of insurance (unlike banking and securities, insurance currently
has no federal regulatory framework), and states also hold the right to
tax insurers.[167]
To protect state regulation of insurance, Congress ensured that federal
statutes not identified in the Act or not yet enacted would not automatically
override state insurance regulation. Section 2(b) provides that when Congress
enacts a law specifically relating to the business of insurance, that law
controls. See § 1012(b). The subsection further provides that
federal legislation general in character shall not be “construed to invalidate,
impair, or supersede any law enacted by any State for the purpose of regulating
the business of insurance.”[168]
Today, however, the Supreme Court interprets this to mean that, so long
as a federal law does not directly conflict with state regulation, McCarran-Ferguson
has no preemptive power unless the federal law interferes with state regulatory
schemes or frustrates a declared state policy.[169]
V.
Humana v. Forsyth: The New Frontier
With this narrowed reading of McCarran-Ferguson’s preemptive authority,
the Supreme Court unanimously simplified the process of filing RICO claims
against insurers. As one group of plaintiff’s attorneys quickly announced,
“In light of [Humana], lawyers representing policyholders or claimants
victimized by the fraud of an insurance company, broker, or agent should
very seriously consider bringing RICO claims. These lawyers should
take note that courts across the country as well as the United States Supreme
Court are reining in the McCarran-Ferguson Act.”[170]
In Humana, the Supreme Court determined that under the plain meaning
of McCarran-Ferguson, RICO claims asserted by a group of health insurance
purchasers against their insurer were not barred.[171] The Court
rejected the notion that Congress may have intended to “cede the field
of insurance regulation to the States, saving only instances in which Congress
expressly orders otherwise.”[172] Instead, the Court concluded that
RICO complements the state regulatory framework for fighting insurance
fraud, and advances the state’s interest. Indeed, according to the
Court, allowing RICO claims against insurers neither impairs state regulation
nor interferes with an insurer’s compliance with state law.[173]
Consequently, RICO suits are no longer precluded under McCarran-Ferguson.
The Supreme Court has declared that no impairment of state insurance law
is present, so long as the new test for impairment is met. The test
now provides that, “when federal law is applied in aid or enhancement of
state regulation, and does not frustrate any declared state policy or disturb
the State’s administrative regime, the McCarran-Ferguson Act does not bar
the federal action.”[174]
According to one expert, lower courts that addressed this McCarran-Ferguson
issue prior to Humana “were split both as to the standard of analysis of
impairment of state law and as to allowance or preclusion of RICO claims
against insurers.”[175] While some courts had applied a liberal “direct
conflict” test,[176] other courts “applied a kind of ‘upset the balance’
test, appearing to scrutinize possible conflicts between RICO and state
remedies in order to preclude RICO claims against insurance companies.”[177]
Because these tests each focus on the similarities or compatibility between
state insurance law and RICO claims, insurers must still scrutinize applicable
state laws. Arguments will need to address whether application of
RICO would interfere with existing state remedies or state policies.
As one attorney explains, “Among other things, of importance to such arguments
may be whether a state has an insurance code that provides a private right
of action for insurance fraud, recognizes tort claims for contractual bad
faith, or has serious limitations on punitive damages.”[178]
VI.
Concluding Remarks
Soon after Humana opened the door for an increased number of RICO claims
against insurers by lowering the threshold for McCarran-Ferguson impairment
findings, plaintiffs’ attorneys announced their intention to increase RICO
filings against life and health insurers.[179] In particular, filings
against HMOs increased dramatically in the final months of 1999, due in
large part to activity among the nation’s most prominent members of the
plaintiffs’ bar. Forming a group they call REPAIR (RICO and ERISA
Prosecutors Advocating for Insurance Industry Reform), the attorneys are
using sizable war-chests from tobacco settlements to fund class action
suits against the nation’s largest HMOs. Their claims focus on ERISA
and RICO violations.[180]
It is hard to imagine that ERISA preemption of most state tort and contract
remedies does not increase the frequency of federal RICO claims which are
not preempted, but which afford recovery to both plaintiffs and their attorneys
that far surpasses remedies available under ERISA. How many of these
suits prevail, and how many continue to be filed, will depend greatly on
interpretations of the Herdrich distinctions. As the Trial Lawyers
for Public Justice wrote in their Humana amicus brief,
[RICO] is tailor-made for rooting out frauds occurring in the health,
life, and property and casualty insurance industries. In cases of
health insurance fraud . . . state law claims against health insurance
plans covered by ERISA are preempted. Remedies under ERISA are limited
. . . even when state law claims are available and not preempted by ERISA
. . . they lack RICO’s powerful remedies and are not as effective in eradicating
fraud.[181]
The powerful effect ERISA has in driving RICO litigation seems evident
in the sheer number of suits where both claims are raised against insurers.
Legal databases indicate that more than forty-five have been decided since
1985. The problem has not gone unnoticed in Congress, where Representative
Charlie Norwood (R-Georgia) is looking to include language in his Norwood-Dingell
health reform bill to protect managed care companies from punitive damages
(so long as they meet standards of care mandated in the bill), and to prohibit
class-action lawsuits under ERISA. Citing the rising use of RICO against
insurers, Representative Norwood says he hopes the bill also will serve
to limit the use of RICO, which was intended to fight organized crime.[182]
From a policy perspective, the current use of ERISA and RICO is questionable,
resulting in many calls for congressional reform. For employers and
insurers, the uniform system of laws under ERISA remains beneficial.
However, its extension to employer-sponsored health insurance and to many
of the other areas that courts have labeled “welfare benefit plans” holds
dubious value.
As for RICO litigation, the Supreme Court has acknowledged that the
law no longer conforms to its original intent, and has called upon Congress
to reform the law. Perhaps it is time for the insurance industry
to press for such a change, supporting a version of Representative Norwood’s
proposed language. While the plaintiffs’ bar may view RICO’s large
awards as a powerful weapon for change, the insurance industry justifiably
could argue that RICO damages are dispensed in an unpredictable manner,
driving up the cost of insurance without providing clear guidance on how
to behave.
Endnotes
[1] Humana v. Forsyth, 525 U.S. 299, 303
(1999).
[2]
Herdrich v. Pegram, 154 F.3d 362 (7th Cir. 1998), rev’d, Pegram v. Herdrich,
68 U.S.L.W. 4501 (June 12, 2000) (mixed medical treatment and eligibility
decisions by HMOs and their physicians are not fiduciary acts within the
meaning of ERISA).
[3]
California Div. of Labor Std. Enforcement v. Dillingham Constr., 519 U.S.
316, 334-35 (1997) (per curiam) (Scalia, J., concurring).
[4] Jayne
E. Zanglein, 5 A.B.A. Preview S. Ct. Cases 278 (Feb. 12, 1999) (citing
Mertens v. Hewitt Associates, 508 U.S. 248, 251 (1993), 120 Cong. Rec.
29,942 (1974) (remarks of Senator Javits)).
[5] Joseph
R. Simone, et al, Fiduciary Responsibility and Prohibited Transactions
Under ERISA, 421 P.L.I./Tax 513 (1998).
[6] Pilot
Life Ins. Co. v. Dedeaux, 481 U.S. 41, 44 (1987) (citing 29 U.S.C. §
1002(1)).
[7]
Dillingham Constr., 519 U.S. at 326-27 (citations omitted).
[8]
Corporate Health Ins. Inc. v. Texas Dept. Ins., 12 F. Supp. 2d 597, 611
(S.D. Tex. 1998) (citations and quotations omitted).
[9] ERISA
Preemption: Hearings Before the Subcomm. on Labor, Health and Human Services
and Education of the Senate Comm. on Appropriations, 105th Cong. (1998)
<http://www.appwp.org/testimony/testimony-gallagher.htm>(statement by
Robert Gallagher, Principal Groom Law Group, on behalf of the Assoc. of
Private Pension and Welfare Plans) (citing 120 Cong. Rec. 29933 (Aug.
22, 1974)(remarks of Sen. Javits))[hereafter Gallagher].
[10] Id.
[11] 29 U.S.C.
§ 1144.
[12]
Elizabeth J. Bondurant, et al, A New Look at Old Problems in Life Insurance,
1999 Conference on Life Ins. Lit., SD65 ALI-ABA 333, 353.
[13]
American Psychological Association, Poll Finds Overwhelming Public Support
for Legal Accountability of All Managed Care Health Plans, (May 1998) <http://www.apa.org/releases/parcarelease.html>.
[14]
Barry R. Furrow, et al. Health Law: Cases, Materials and Problems
304 (3d Ed. 1997).
[15]
Bondurant , supra note 12, at 353 (citing 29 U.S.C. § 1003).
[16] Parrino v.
FHP Inc., 146 F.3d 699, 703 (9th Cir. 1998) (finding that ERISA preempted
all claimant’s state law claims).
[17] Id. (citing
Carver v. Westinghouse Hanford Co., 951 F.2d 1083, 1086 (9th Cir. 1991)).
[18]
Meredith v. Time Ins. Co., 980 F.2d 352, 355 (5th Cir. 1993).
[19]
Corporate Health, 12 F. Supp. 2d at 608 (S.D. Tex. 1998) (citing Fort Halifax
Packing Co. v. Coyne, 482 U.S. 1, 11 (1987)).
[20]
Jayne Zanglein, ERISA draft at 9 (citing Dillingham Constr., 688 F.2d at
1371).
[21] 29 U.S.C.A.
§ 1002(1) (West Supp. 1998).
[22]
Corporate Health, 12 F. Supp. 2d at 608.
[23] Id.
[24] Id.
[25] Otto v. Variable
Annuity Life Ins. Co., 814 F.2d 1127, 1134-5 (7th Cir. 1986).
[26] Id. at 1135
(quoting plaintiff).
[27] Id. at 1135.
[28] Corporate
Health, 12 F. Supp. 2d at 609.
[29] 29 USC §
1003(a)(1).
[30]
Bondurant, supra note 12, at 355 (citing Winterrowd v. David Freedman &
Co., 724 F.2d 823, 825 (9th Cir. 1984)).
[31] Pilot Life
Ins. Co. v. Dedeaux, 481 U.S. 41, 44 (1987) (citing 29 U.S.C. § 1002(1)).
[32]
Bondurant, supra note 12, at 353-54 (terms in quotations marks are defined
in the ERISA statute).
[33] Id. at 353.
[34]
Dedeaux, 481 U.S. at 46.
[35] State law
includes “all laws, decisions, rules, regulations, or other State action
having the effect of law of any State.” 29 USC § 1144(c)(1).
[36]
Midwest Security Life Ins. Co. v. Stroup, 706 N.E.2d 201, 204 (Ind. Ct.
App 1999).
[37] Id. (citing
several Supreme Court decisions).
[38] Camp v. Pacific
Fin. Group, 956 F. Supp. 1541, 1544 (C.D. Cal 1997) (citing Metropolitan
Life Ins. Co. v. Massachusetts, 471 U.S. 724, 739 (1985)).
[39] Id. at 1544-49.
[40]
California Div. of Labor Std. Enforcement v. Dillingham Constr., 519 U.S.
316, 334-35 (1997) (Scalia, J., concurring).
[41] Id. at 324
(citing New York State Conference of Blue Cross and Blue Shield Plans v.
Travelers Ins. Co., 514 U.S. 645, 656 (1995); Metropolitan Life Ins. Co.
v. Massachusetts, 471 U.S. 724, 739 (1985); Pilot Life Ins. Co. v.
Dedeaux, 481 U.S. 41, 47 (1987); Ingersoll-Rand Co. v. McClendon,
498 U.S. 133, 138 (1990); Morales v. Trans World Airlines, Inc., 504 U.S.
374, 384 (1992); FMC Corp. v. Holliday, 498 U.S. 52, 58 (1990)).
[42] Id. at 325.
[43]
Midwest Security Life Ins. Co. v. Stroup, 706 N.E.2d 201, 204-05 (Ind.
Ct. App 1999).
[44] Id.
[45] Camp v. Pacific
Fin. Group, 956 F. Supp. 1541, 1544 (C.D. Cal 1997).
[46]
Dedeaux, 481 U.S. at 44-45 (“Congress capped off the massive undertaking
of ERISA with three provisions relating to the pre-emptive effect of the
federal legislation.”).
[47] Id. at 45.
[48]
McCarran-Ferguson Act, § 2(b), 15 U.S.C.A. § 1012(b).
[49] Camp, 956
F. Supp. at 1546.
[50] Id. at 1550.
[51]
Moreland v. Behl, No. C-92-1238 MHP, 1995 U.S. Dist. LEXIS 15353, at *8
(N.D. Cal. Oct. 4, 1995).
[52]
Bondurant, supra note 12, at 358.
[53] Id. at 359.
[54] Parrino v.
FHP Inc., 146 F.3d 699, 705 (9th Cir. 1998) (citations omitted).
[55] 29 U.S.C.
§ 1144(a).
[56]
Phommyvong v. Muniz, No. CIV.A. 3:98-CV-0070-L, 1999 WL 155714, at *2 (N.D.Tex.
Mar. 11, 1999).
[57] New York
State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins.
Co., 514 U.S. 645, 662 (1995).
[58]
Phommyvong, 1999 WL 155714, at *2 (citing Sommers Drug Stores v. Corrigan
Enterprises, Inc., 793 F.2d 1456, 1467 (5th Cir. 1986), cert. denied, 479
U.S. 1034 (1987)).
[59] Id. at *3-4
(citing Dukes v. U.S. Healthcare, Inc., 57 F.3d 350, 357 (3d Cir. 1995),
cert. denied, 516 U.S. 1009 (1995)).
[60] See, e.g.,
Armand v. Kaiser Found. Health Plan of Texas, 12 F. Supp.2d 556 (N.D.Tex.
1998); Giles v. NYLCare Health Plans, Inc., 172 F.3d 332 (5th Cir. 1999);
Herdrich v. Pegram, 154 F.3d 362 (7th Cir. 1998); Ries v. Humana Health
Plan, Inc., 1995 WL 669583, at *7 (N.D. Ill. 1995); Silva v. Kaiser Permanente,
59 F. Supp.2d 597 (N.D.Tex. 1999); Anderson v. Humana, Inc., 24 F.3d 889
(7th Cir. 1994); Phommyvong, 1999 WL 155714 *1.
[61] Pegram v.
Herdrich, 68 U.S.L.W. 4501 (June 12, 2000).
[62] Silva, 59
F. Supp.2d at 599.
[63] Id at 599.
(citing Hubbard v. Blue Cross & Blue Shield Assn., 42 F.3d 942 (5th
Cir.), cert. denied, 515 U.S. 1122 (1995) (claim regarding denial of cancer
treatments deemed “experimental” by plan guidelines was preempted by ERISA);
Jass v. Prudential Health Care Plan, Inc., 88 F.3d 1482 (7th Cir. 1996)
(negligence claim arising out of utilization review program’s denial of
physical therapy was preempted as a “denial of benefit” claim under ERISA).
[64] One court
has characterized ERISA preemption of claims against an HMO as “slam[ming]
the courthouse doors in [the plaintiff’s] face and leav[ing] her without
any remedy . . . This case, thus, becomes yet another illustration
of the glaring need for Congress to amend ERISA for the changing realities
of the modern health care system. Enacted to safeguard the interests
of employees and their beneficiaries, ERISA has evolved into a shield of
immunity that protects health insurers, utilization review providers, and
other managed care entities from potential liability for the consequences
of their wrongful denial of health benefits.” Andrews-Clarke v. Travelers
Ins. Co., 984 F. Supp. 49, 53 (D. Mass. 1997). See also Tolton v. American
Biodyne, Inc., 48 F.3d 937, 943 (6th Cir.1995) ("One consequence of ERISA
preemption, therefore, is that plan beneficiaries or participants bringing
certain types of state actions--such as wrongful death--may be left without
a meaningful remedy."); Corcoran v. United Healthcare, Inc., 965 F.2d 1321,
1338-39 (5th Cir. 1992) ("The result ERISA compels us to reach means the
[Plaintiff has] no remedy, state or federal, for what may have been a serious
mistake."); Turner v. Fallon Community Health Plan, 953 F.Supp. 419, 424
(D.Mass.1997) (Gorton, J.), aff'd, 127 F.3d 196 (1st Cir.1997) ("An unfortunate
consequence of ERISA preemption is, therefore, that plan beneficiaries
or participants who bring certain kinds of state actions, e.g., wrongful
death, may be left without a meaningful remedy . . . . Sadly, the case
at bar compels a like result. Plaintiff's state common law claims are preempted
by the broadly sweeping arm of ERISA. Plaintiff is left without any meaningful
remedy even if he were to establish that [the insurer] wrongfully refused
to provide the [bone marrow transplant] his wife urgently sought.").
[65]
Bondurant, supra note 12, at 359 (citing 29 U.S.C. § 1132(a)(1)(B)).
[66] Id. at 360
(citing Massachusetts Mutual Life Ins. Co. v. Russell, 473 U.S. 134 (1985)).
[67] Id.
[68]
Metropolitan Life Ins. Co. v. Socia, 16 F. Supp. 2d 66, 73 (Mass. 1998)
(internal citations omitted).
[69]
Bondurant, supra note 12, at 360.
[70] Id. at 361.
[71] Id. at 361
(citing Graham v. Federal Express Corp., 725 F. Supp. 429, 437 (W.D. Ark.
1989) (holding that “the failure to comply with reasonable time constraints
prescribed by the plan’s review procedure precludes judicial review of
a claim for benefits.”).
[72] Id. (citations
omitted).
[73] Id. at 362.
[74] Id.
[75]
Simone, supra note 5, at 517.
[76] Id. at 518.
[77] 29 U.S.C.
§ 1002(21)(A).
[78]
Simone, supra note 5, at 519.
[79]
Gallagher, supra note 9.
[80]
Simone, supra note 5, at 519.
[81] Id. at 519-20.
[82] Id. at 520.
[83] Id. at 521-22.
[84] Id. at 533-34.
[85]
Although punitive damages generally are not available under ERISA, a defendant
found guilty of embezzling funds from an ERISA-qualified pension fund was
assessed treble damages of almost $2 MM under RICO. Simone, supra note
5, at 100 (citing Crawford v. La Boucherie Berndard, Ltd., 815 F.2d 117
(D.C.Cir. 1987), cert. denied, 484 U.S. 943 (1987)).
[86]
Herdrich v. Pegram, 154 F.3d 362, 372 (7th Cir. 1998) (citing Ries v. Humana
Health Plans, Inc., 1995 WL 669583 *7 (N.D.Ill. 1995)).
[87] Id. at 372.
[88] Id. at 371
(citations omitted).
[89] Id. at 372.
[90] Id. at 373.
[91] Id. at 370.
[92] Id. at 380
(citing Massachusetts Mut. Life Ins. Co. v. Russell, 473 U.S. 134 (1985)).
[93] Id.
[94] See IT Corp.
v. General American Life Ins. Co., 107 F.3d 1415 (9th Cir. 1997); Libbey-Owens-Ford
Co. v. Blue Cross & Blue Shield Mut. of Ohio, 982 F.2d 1031 (6th Cir.
1993); Weiss v. Cigna Healthcare, Inc., 972 F. Supp. 748 (S.D.N.Y. 1997);
Drolet v. HealthSource, Inc., 968 F. Supp. 757 (D.N.H. 1997).
[95] Weiss, 972
F. Supp. at 751 (citing O’Reilly v. Ceuleers, 912 F.2d 1383, 1385 (11th
Cir. 1990); Morales v. Health Plus Inc., 954 F. Supp. 464, 468-69 (D.P.R.
1997)).
[96] Id.
[97] Id. at 752-53.
[98] Id.
[99] Drolet, 968
F. Supp. at 761 (citing Varity Corp. v. Howe, 516 U.S. 489, 511 (1996)
(noting that "a plan administrator engages in a fiduciary act when making
a discretionary determination about whether a claimant is entitled to benefits
under the terms of the plan documents"); Libbey?Owens?Ford Co., 982 F.2d
1031, 1035 ("When an insurance company administers claims for [a
plan] and has authority to grant or deny the claims, the company is an
ERISA 'fiduciary' . . ."); American Fed'n of Unions v. Equitable Life Assurance
Soc'y, 841 F.2d 658, 663 (5th Cir.1988).
[100] Id. (citing Libbey?Owens?Ford
Co., 982 F.2d 1031, 1035).
[101] Id. (citing American
Fed'n of Unions, 841 F.2d at 663).
[102]
Pegram v. Herdrich, 68 U.S.L.W. at 4504 (citing Webster’s New International
Dictionary 1879 (2d ed. 1957)).
[103]
Id.
[104]
Id. at 4505.
[105]
Id.
[106]
Id.
[107]
Id.
[108]
Id. at 4506.
[109]
Id.
[110]
Id. at 4507.
[111] See press release by
Richard Scruggs regarding his filing of a class action against AETNA:
“Our class action is designed to transform the entire system so that no
patient is ever again harmed by an HMO.” Oct. 7, 1999, “National Class
Action Lawsuit Filed Against the Nation’s Largest HMO Charging, RICO, ERISA
Violations,” <http://wwwprnewswire.com.>
[112]
METHODOLOGY: On Oct. 28, 1999, the author ran several keyword searches
in the Federal case law databases of Lexis and Westlaw, looking for suits
against life and health insurers involving both RICO and ERISA claims.
After a cursory examination of the results, it appears that more than 45
of the cases address issues similar to those reviewed in this paper.
[113]
Humana v. Forsyth, 525 U.S. 299, 302 (1999).
[114] Ernest W. Irons, RICO:
Get Ready For the Onslaught, ABA 16-Fall Brief 24 (1986).
[115] P.R. Newswire, National
Class Action Lawsuit Filed Against Nation’s Largest HMO Charging, RICO,
ERISA Violations (released Oct. 7, 1999) <http://www.prnewswire.com
>.
[116] Ernest W. Irons, supra
note 114, at 24.
[117] Id. at 25 (quoting 18
U.S.C. § 1964(c)).
[118] Sutton v. United Airlines,
527 U.S. 471, 119 S. Ct. 2139, 2157-58 (1999) (citing H.J. Inc. v. Northwestern
Bell Telephone Co., 492 U.S. 229 (1989)).
[119] Id.
[120]
Alexander v. United States, 509 U.S. 544, 562 (1993) (citing Pub.L. 91-452,
Title IX, 84 Stat. 941, as amended, 18 U.S.C. §§ 1961-1968 (1988
ed. and Supp. III), S.Rep. No. 91-617, p. 79 (1969), 18 U.S.C. § 1961(5)).
[121] Patrick Strawbridge,
Insurer Faces Lawsuit: Class Action Under a Racketeering Law Accused United
Healthcare of Overcharging Customers, Omaha World-Herald, Apr. 23, 1999,
available in 1999 WL 449674.
[122] Irons, supra note 114,
at 25-26, (quoting Sedima, S.P.R.L. v. Imrex Co., 473 U.S. 479 (1985)).
[123] Id. at 24.
[124] Sabo v. Metropolitan
Life Ins. Co., 137 F.3d 185, 193 (3d Cir. 1998), cert. denied, 119 S.Ct.
918 (1999).
[125] Irons, supra note 114,
at 24-25.
[126] Id. at 33 (quoting 18
U.S.C. § 1961(5)).
[127] Maio v. Aetna, Inc.,
No. 99-1969, 1999 U.S. Dist. LEXIS 15056, at *4 (E.D. Pa. Sep. 29, 1999)
(citing 18 U.S.C. § 1964).
[128]
Framingham Union Hosp. v. Travelers Ins. Co., 721 F. Supp. 1478, 1484 (D.Mass.
1989) (citing Norman v. Brown, Todd & Heyburn, 693 F. Supp. 1259, 1263
(D.Mass 1988)).
[129]
Cunningham v. PFL Life Ins. Co., 42 F. Supp. 2d 872, 881 (N.D. Iowa 1999).
[130] Otto v. Variable Annuity
Life Ins. Co., 814 F.2d 1127, 1136 (7th Cir. 1986).
[131] Id. at 1137.
[132]
Bachman v. Bear-Stearns & Co., 178 F.3d 930, 932 (7th Cir. 1999).
[133] Lisa Pritchard Bailey
et al, Racketeer Influenced and Corrupt Organizations, 36 Am. Crim. L.Rev.
1035, 1051 (Summer 1999) (citing Handeen v. Lemaire, 112 F.3d 1339, 1351
(8th Cir. 1997)).
[134] Id. (citing Handeen
v. Lemaire, 112 F.3d 1339, 1351 (8th Cir. 1997)).
[135]
Moreland v. Behl, No. C-92-1238 MHP, 1996 WL 193843, at *23 (N.D.Cal. Apr.
17, 1996).
[136] Id. at *23 (citing Chang
v. Chen, C-94-555583, 1996 WL 155015 (9th Cir. 1996)).
[137] Id. (citing Sun Sav.
and Loan Ass’n v. Dierdorff, 825 F.2d 187, 195 (9th Cir. 1987)).
[138]
Cunningham v. PFL Life Ins. Co., 42 F. Supp. 2d 872, 884 (N.D. Iowa 1999).
[139] Davis v. Mutual Life
Ins. Co. of New York, 6 F.3d 367 (6th Cir. 1993).
[140] Id. at 376-7.
[141] Id. at 377.
[142] Id. 377-80.
[143] Maio v. Aetna, Inc.,
No. 99-1969, 1999 U.S. Dist. LEXIS 15056, at *8 (E.D. Pa. Sep. 29, 1999).
[144] Id.
[145]
Associates in Adolescent Psychiatry v. Home Life Ins. Co., 941 F.2d 561
(7th Cir. 1991).
[146] Id. at 570 (citing 18
U.S.C. § 1961(1)).
[147]
Framingham Union Hosp. v. Travelers Ins. Co., 721 F. Supp. 1478 (D.Mass.
1989).
[148] Id. at 1484.
[149] Id.
[150]
Robinson v. Hawkins, 942 F. Supp. 1234 (E.D.Mo. 1996).
[151] Id. at 1235, 1237-38.
[152] Id. at 1238 (quoting
H.J. Inc. v. Northwestern Bell Tel. Co., 492 U.S. 229, 239 (1989)).
[153] Id. (quoting H.J. Inc.,
492 U.S. at 241 (1989)).
[154] Id. (quoting H.J. Inc.,
492 U.S. at 242 (1989)).
[155] Berent v. Kemper Corp.,
973 F.2d 1291, 1294 (6th Cir. 1992). See also Moreland, 1996 WL 193843,
at *22.
[156]
Moreland v. Behl, No. C-92-1238 MHP, 1996 WL 193843, at *22 (N.D.Cal. Apr.
17, 1996) (citing United States v. Green, 745 F.2d 1205, 1207 (9th Cir.
1984), cert. denied, 474 U.S. 925 (1985)).
[157] Camp v. Pacific Fin.
Group, 956 F. Supp. 1541, 1550-51 (C.D. Cal 1997) (citing Schreiber Distrib.
Co. v. Serv-Well Furniture Co., 806 F.2d 1393, 1399-1400 (9th Cir. 1986)).
[158] Berent, 973 F.2d at
1295.
[159] Id.
[160]
Harper-Wyman Co. v. Connecticut Gen. Life Ins. Co., No. 86 C 9595, 1991
WL 285746, at *1 (N.D.Ill. Dec. 23, 1991).
[161] Id. at *8.
[162] Id. at *9.
[163]
Humana v. Forsyth, 525 U.S. 299, 302 (1999).
[164] 15 U.S.C. § 1012(b).
[165]
Humana, 525 U.S. at 302.
[166] Id. at 306 (citing United
States v. South-Eastern Underwriters Assn., 322 U.S. 533 (1944)).
[167] Id.
[168] Id.
[169] Id. at 308.
[170] Eugene R. Anderson,
et al, Fighting Insurance Company Fraud with RICO: The Supreme Court
Clears the Way Under the McCarran-Ferguson Act, 22 Am.J. Trial Advoc. 267,
294 (1998).
[171]
Humana v. Forsyth, 525 U.S. 299, 307 (1999).
[172] Id. at 308.
[173] Id. at 307.
[174] Id. at 303.
[175] Robert B. Lowry, Supreme
Court RICO Decision Against Health Insurer Changes Scene For Insurance
Fraud Claims, Bullivant, Houser & Bailey Web Site, http://www.bullivant.com/news-pubs-I99a.htm
.
[176] See Forsyth v. Humana,
Inc., 99 F.3d 1504, 1515-16 (9th Cir. 1996); Merchants Home Delivery Serv.
Erv., Inc. v. Frank B. Ball & Co., 50 F.3d 1486 (9th Cir. 1995).
[177] Lowry, supra note 175
(citing DOE v. Norwest Bank Minnesota, N.A., 107 F.3d 1297, 1307 (8th Cir.
1997) (RICO found to "impair" Minnesota insurance regulatory program because
of RICO’s substantially different damage provisions); Kenty v. Bank One
Columbus, N.A., 92 F.3d 384, 392 (6th Cir. 1996) (RICO would "impair" Ohio
regulatory scheme having different liability and damage provisions and
different standards of proof)).
[178] Id.
[179] See REPAIR Team Strikes
Again, Business & Health, Jan. 1, 2000, available in 2000 WL
9502213; Money Talks in HMO Class Action Lawsuits, Business & Health,
Dec. 1, 1999, available in 1999 WL 10663563; Plaintiff’s Lawyers
Step Up Pressure Against HMOs, Liability Week, Nov. 29, 1999, available
in 1999 WL 13960687; Norwood Seeks Amendment Barring HMO Class-Action Suits,
Best's Ins. News, Jan. 12, 2000, available in 2000 WL 4084395.
[180]
REPAIR Team Strikes Again, Business & Health, Jan. 1, 2000, available
in 2000 WL 9502213.
[181] More Amici Briefs Filed
in Policyholders’ RICO Claims Against Humana, 4 Andrews Health Care Fraud
Litig. Reporter (Rep. 10), Jan. 1999 (no page numbers avail.).
[182]
Norwood Seeks Amendment Barring HMO Class-Action Suits, Best's Ins. News,
Jan. 12, 2000, available in 2000 WL 4084395.
(Author’s bio)
Katherine
W. Fairborn graduated from Texas Tech School of Law this past Spring summa
cum laude, and was inducted in Phi Kappa Phi and the Order of the Coif.
She will begin work as an associate in the Insurance Law section of the
Austin office of Akin, Gump, Strauss, Hauer & Feld in the Fall. Before
she returned to law school, Mrs. Fairborn received her B.A. and M.B.A.
from the University of Texas, Austin. She has eight years of experience
working in the workers’ compensation and life insurance industries.
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