OTHER HEALTH CONCEPTS · 6 MIN READ

ERISA Claims, Subrogation, and Equitable Remedies

When an ERISA plan denies benefits, the participant's lawsuit lives inside ERISA's civil enforcement section. A claim to recover plan benefits proceeds under §502(a)(1)(B); broader plan-wide fiduciary breach claims and suits for 'appropriate equitable relief' have their own subsections, and courts read the equitable category narrowly — legal money damages are not available. The standard of review comes from Firestone v. Bruch: denials are reviewed de novo unless the plan document grants the administrator discretionary authority, in which case courts apply the deferential abuse-of-discretion standard. Metropolitan Life v. Glenn added the conflict-of-interest overlay: when the same entity both decides claims and pays them from its own funds, that structural conflict does not change the standard but must be weighed as one factor among many — heavier where the conflict likely influenced the decision, lighter where safeguards insulate claims handling. Hardt v. Reliance Standard set the attorneys-fee bar: a court may award fees to a party achieving 'some degree of success on the merits,' less than prevailing-party status — even a remand can qualify. Heimeshoff upheld reasonable plan-written limitation periods for filing suit, such as a three-year contractual deadline. The same equitable-relief limits shape health-plan subrogation and reimbursement. In Sereboff v. Mid Atlantic, the Supreme Court held a plan can enforce its reimbursement clause under ERISA as an equitable lien by agreement — but only against specifically identifiable funds traceable to the third-party recovery and still in the participant's possession. US Airways v. McCutchen added that clear plan language controls: unambiguous reimbursement terms override equitable defenses like the made-whole doctrine (the default rule that an insurer recovers nothing until the insured is fully compensated) and the common fund doctrine (which otherwise charges the insurer a share of the attorney's fees that produced the recovery) — though silence in the plan lets those defaults apply. Two boundary doctrines complete the picture. The anti-subrogation rule forbids an insurer from subrogating against its own insured for a risk the policy covers — it cannot claw back from the very person it agreed to protect. And federal statutes can write their own scheme: under §33 of the LHWCA, the employer/insurer that paid longshore benefits holds a statutory first-priority lien on the worker's net third-party recovery, with a credit against future compensation — a structure that displaces state common-law rules like made-whole.