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Abstract

According to 2001 U.S. Census data, approximately sixty-three percent of the population receive their health care benefits from employer- sponsored health care plans. Recognizing the growing number and economic impact of employee benefit plans, Congress enacted the Employee Retirement Income Securities Act (ERISA) in 1974 to regulate employee pension benefit plans and employee welfare benefit plans, which include employer-sponsored health care plans. According to ERISA section 2(b), one of the Act's purposes is to protect the interests of heath care plan participants and beneficiaries by requiring the disclosure of information regarding the plan and providing adequate remedies for breaches of the plan. Recently the Eighth Circuit, relying in part on section 2(b)'s stated purpose of protecting plan participants, affirmed a district court's summary judgment against a health plan in Christianson v. Poly- America Med. Benefit Plan. The health plan excluded coverage for conditions related to tobacco use. The Eighth Circuit found that, despite the plan participant's tobacco use, his deep-vein thrombosis was not sufficiently "related to" his condition under the plan language. However, despite section 2(b)'s directive, to protect plan participants, the Supreme Court's interpretation of ERISA's preemption scheme has allowed self-insured plans to protect themselves against state laws regulating the substantive content of health plans. Therefore, many plans are free to completely exclude coverage to groups of individuals or for particular illnesses. Court decisions adverse to plans, such as Christianson, may spur self-insured plans to eliminate coverage completely for certain groups and illnesses rather than to carve out exclusions to general coverage. In addition, plan administrators' decisions are reviewed by courts under an abuse-of-discretion standard, and the most substantial costs plan sponsors could face for wrongfully denying benefits are the costs of the benefits plus attorneys' fees, court costs, and prejudgment interest. The legal system clearly favors health plans over plan participants and beneficiaries. In Part II, this Note begins with a brief discussion about how ERISA preemption and civil enforcement favor plans over participants. This Note then explains the Christianson decision in Part III, detailing the facts surrounding the case and describing Christianson's victory. The Eighth Circuit held that Poly-America's exclusion of tobacco- related conditions did not apply to Christianson's deep-vein thrombosis despite his tobacco use. Section IV.A discusses reasons why employers may target smoking and ways they will try to exclude smoking-related illnesses from health plans. Employers are not required to offer their employees health coverage, and employers will only be able to keep their plans operating if they are able to control their exposure to rising health care costs. Employers have begun to attempt to save money by limiting the coverage they provide to employees who engage in voluntary, risk-taking behavior such as smoking. Section IV.B demonstrates that, despite these efforts, employers may have a difficult time enforcing these restrictions. This Note concludes by noting that although individual smokers may have a few successes in winning benefits from their health plans, these successes will only encourage health plans to eliminate smokers as a group from any health care coverage. Although ERISA permits the exclusion of tobacco-related conditions from plan coverage, plan administrators will find it too difficult to carry out such exclusions and ultimately will be forced to terminate coverage for smokers altogether.

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