US Airways, Inc. v. McCutchen

ERISA: health benefits plan: interpretation of its terms: the health benefits plan established by petitioner US Airways paid $66,866 in medical expenses for injuries suffered by respondent McCutchen, a US Airways employee, in a car accident caused by a third party. The plan entitled US Airways to reimbursement if McCutchen later recovered money from the third party. McCutchen’s attorneys secured $110,000 in payments, and McCutchen received $66,000 after deducting the lawyers’ 40% contingency fee. US Airways demanded reimbursement of the full $66,866 it had paid. When McCutchen did not comply, US Airways filed suit under §502(a)(3) of the Employee Retirement Income Security Act of 1974 (ERISA), which authorizes health-plan administrators to bring a civil action “to obtain . . . appropriate equitable relief . . . to enforce . . . the terms of the plan.”; in Sereboff v. Mid Atlantic Medical Services, Inc., 547 U. S. 356, the Court permitted a health plan administrator to bring a suit just like this one. The administrator’s claim to enforce its reimbursement clause, the Court explained, was the modern-day equivalent of an action in equity to enforce a contract-based lien—called an “equitable lien ‘by agreement.’ ” Id., at 364–365; while McCutchen’s equitable rules cannot trump a reimbursement provision, they may aid in properly construing it. US Airways’ plan is silent on the allocation of attorney’s fees, and the common fund doctrine provides the appropriate default rule to fill that gap. Ordinary contract interpretation principles support this conclusion. Courts construe ERISA plans, as they do other contracts, by “looking to the terms of the plan” as well as to “other manifestations of the parties’ intent.” Firestone Tire & Rubber Co. v. Bruch, 489 U. S. 101, 113. Where the terms of a plan leave gaps, courts must “look outside the plan’s written language” to decide the agreement’s meaning, CIGNA Corp. v. Amara, 563 U. S. ___, ___, and they properly take account of the doctrines that typically or traditionally have governed a given situation when no agreement states otherwise; because a party would not typically expect or intend a plan saying nothing about attorney’s fees to abrogate so strong and uniform a background rule, a court should be loath to read the plan in that way. The common-fund rule’s rationale reinforces this conclusion: without the rule, the insurer can free ride on the beneficiary’s efforts, and the beneficiary, as in this case, may be made worse off for having pursued a third party. A contract should not be read to produce these strange results unless it specifically provides as much (U.S. S. Ct., 16.04.13, US Airways, Inc. v. McCutchen, J. Kagan).

ERISA et plans de santé : interprétation de leurs termes : l'administrateur du plan de santé ouvre action contre l'un de ses bénéficiaires, victime d'un accident de circulation,  pour obtenir remboursement des indemnités avancées par le plan de santé, le responsable ayant entretemps indemnisé la victime. Les règles ordinaires d'interprétation des contrats s'appliquent s'agissant d'interpréter les clauses d'un tel plan de santé. Il s'agit de se fonder sur les termes utilisés par les parties et sur les autres manifestations de l'intention des parties. Quand le contenu du plan ne répond pas à une question, l'interprétation se fait par des éléments extrinsèques. Est ici pris en compte le fait qu'une partie ne s'attend pas à ce qu'un plan de santé soit muet au sujet de la prise en compte ou non des frais d'avocat dans le cadre du calcul de la somme à rembourser au plan. Par conséquent, les frais d'avocat doivent être pris en compte, de manière à ce que la victime ne soit pas appauvrie, au surplus appauvrie du fait même de ses efforts pour être indemnisée par le responsable de l'accident de circulation.