Health Administration Responsibility Project
Fiduciary responsibility under ERISA

June 12, 2000
The U.S. Supreme Court has essentially abolished the federal claim of breach of ERISA fiduciary responsibility against a physician or HMO which denies or delays needed medical care for reasons of increasing its own profit.
See Pegram v. Herdrich or its Syllabus.
The cause of action may still be available in state court, and for non-ERISA cases.
see: Moore v. Regents of Calif., 51 Cal.3d 120, 128 (1990)

• 29 USC 1001 - Policy

  "It is...the policy of this chapter to protect... the interests of participants in EBPs and their beneficiaries"

  "continued well-being & security of...employees"

  "...improving the equitable character...of such plans"

  "...desirable to increase the liklihood that full benefits will be paid"

• 29 USC 1104 - Duty of fiduciary

  " to use a Prudent Man standard of care "solely in the interest of the participants"

• 29 USC 1109 - Civil penalties for Breach of fiduciary resp.
• 29 USC 1106 - Prohibited transactions & self-dealing
• Shea v. Esensten 8th Circuit.
  It is a Breach of Fiduciary Responsibility under ERISA not to reveal physician incentives to withold referral, and fiduciaries are liable under ERISA.
  In a 2d look at this case, the 8th Circuit held that Mrs. Shea's State law suits against the Doctors for not revealing their financial incentives were not preempted by ERISA, and could proceed as well!
• Herdrich v. Pegram 7th Circ.
  Doctors who were responsible both for denying medical care and voting themselves bonuses could be sued for fiduciary breach.
  This case was reversed by the Supreme Court. See Pegram v. Hedrich or its Syllabus.
  An excellent article on the significance of Pegram, by Stephen Rosenfeld..
• IT Corp. v. General American 9th Circ.
  An ERISA plan administrator can qualify as a Fiduciary subject to suit by participants, if its authority over denial of benefits is more than 'purely ministerial'.
• One advantage for plaintiffs: The attorney-client privilege and the work-product doctrine may not protect attorney-client communications on plan fiduciary matters from discovery in litigation brought by plan participants or beneficiaries.
  In re Long Island Lighting Co. 129 F.3d 268 (2d Cir, 1997)
• DROLET v. HEALTHSOURCE is a class action suit which was before the federal district court of New Hampshire. It has recently been settled, with Healthsource agreeing to disclosure.
  It alleged breach of fiduciary duty under ERISA, based on witholding of information from members about physician incentives.
  Read the Complaint
  Read the Memo which successfully opposed defendant's motion for summary dismissal.
  Read the Order denying defendant's motion to dismiss for lack of standing and failure to state a cause of action.