The Employee Retirement Income Security Act (“ERISA”) establishes minimum standards for retirement plans in the private industry. These standards include that 1) plans must provide participants with information about the plan, such as plan features and funding; 2) minimum standards for participation, vesting, benefit accrual and funding; 3) accountability of plan fiduciaries; 4) the right for participants to sue for benefits and breaches of fiduciary duty; and 5) payment guarantees of certain benefits if a defined plan is terminated. Among retirement plans, ERISA also covers group health plans, which are welfare benefit plans for employees that are established or maintained by an employer or employee organization, and fiduciaries have certain responsibilities to participants of such plans.
Annette Weil (“Weil”) filed a lawsuit against CIGNA Corporation (“Cigna”) in September 2015 alleging it violated ERISA by not covering a depression treatment sought by Weil. Weil currently suffers from major depressive disorder, and her mental health provider recommended that she undergo a therapy for her depression called repetitive transcranial magnetic stimulation (“TMS”).
Although TMS is an effective and safe treatment, covered by other insurers, Cigna denied coverage to plan participants. Under ERISA, fiduciaries have a duty to determine if a procedure or treatment is medically necessary before denying coverage. Allegedly, Cigna failed to make this determination. The class Weil represents includes 927 people whose TMS claims were denied by Cigna after September 8, 2011.
On April 17, 2017, U.S. District Judge Michael W. Fitzgerald tentatively approved a $2.75 million deal to settle the class’s claims, the deal also required Cigna recognize TMS as a medically appropriate treatment for depression under certain circumstances. However, Judge Fitzgerald was apprehensive of the agreement’s high $25,000 individual award to Weil. According to one class attorney, Andrew Goldfarb, the stigma for people with mental health issues sometimes makes it harder for people to expose themselves to the public, and Weil’s actions made it possible to challenge policies and prompt changes that needed to be made. Thus, Weil’s attorneys found it appropriate to reward her for her courage.
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Eslinger, Bonnie. “Cigna’s $2.7M ERISA Deal Over Depression Cure Nears OK.” Law360. Last modified on April 17, 2017.
United States Department of Labor. “Understanding Your Fiduciary Responsibilities Under a Group Health Plan.” U.S. Department of Labor, Employee Benefits Security Administration. Last modified on September 2015.