IN ORDER to HAVE COMPLETE DISCRETION AS TO BENEFIT DETERMINATIONS, ERISA PLAN DOCUMENTS MUST CLEARLY STATE THAT BENEFIT DETERMINATIONS ARE DISCRETIONARY
美国第七巡回上诉法院在Herzberger案中裁定，ERISA计划文件必须明确赋予管理员自由裁量权，否则法院将进行全面审查，这对雇主和雇员在福利纠纷中的权利有重要影响。
Herzberger v. Prudential Insurance Company of America, 205 F.3d 327 (United States Court of Appeals for the Seventh Circuit--February 23, 2000) Much of the Employee Retirement Income Security Act of 1974 (ERISA) deals with retirement benefits, but much of the daily administration of benefit plans involves health insurance coverage provided by employers, often administered through insurance coverage purchased by the employer. Employee beneficiaries and employers or insurers administering plans often disagree as to coverage, resulting in litigation. A continuing controversy on this front is the degree of freedom a benefit plan administrator (usually a health insurance company claims adjuster) has in denying such claims. For obvious reasons, employers and insurers would prefer that they have total discretion so that any benefit denials are final and not subject to successful court challenges. For equally obvious reasons, beneficiaries prefer to categorize a plan as providing coverage subject to certain contractual standards and norms of acceptable health insurance. Courts have had some difficulty determining from the plan documents whether the plan's decision authority is discretionary or circumscribed. In Herzberger, the Seventh Circuit sought to bring some clarity to its own precedents in an opinion that may be influential in other quarters. Writing for the court, Chief Judge Richard Posner framed the issue as whether language in plan documents to the effect that benefits shall be paid when the plan administrator upon proof (or satisfactory proof) determines that the applicant is entitled to them confers upon the administrator a power of discretionary judgment, so that a court can set it aside only if it was and capricious, that is, unreasonable, and not merely incorrect, which is the question for the court when review is plenary (de novo). The cases directly on point say no, ruling that the language in the plan documents must confer discretion in clearer terms. 205 F.3d at 329, (citations omitted). Finding some of the case law unclear or arguably in tension, the court issued the Herzberger opinion to clarify our position and reduce the tension Id. at 330. In particular, the court found it desirable to have a uniform national rule because of the movement of workers and the multi-state operations of employers. Where plan documents provide no indication of the scope of judicial review, the judicial review is plenary and seeks to determine whether a plan administrator got it right under the terms of the coverage provided by the plan. However, because an ERISA plan is a contract between the employer and employees, the employer is permitted to change the default standard of judicial review from one that is plenary to one that is more deferential, such as the and capricious standard. But to make this change, the plan documents must be sufficiently clear. Where plan document language is ambiguous, the plan is construed as providing plenary review. As with insurance coverage generally, ambiguity is, in effect, construed against the drafter of the documents. However, unless a contract involves something of highly personal taste, such as a commissioned portrait, the widest discretion that can be established is a yardstick of reasonableness. Even where the plan documents do clearly convey discretion to the administrator, the administrator's decisions must be rather than arbitrary or capricious. Although this standard provides some protection to the worker or beneficiary, it benefits the employer because health coverage issues are often sufficiently close or complicated so that both sides can be said to have adopted reasonable or non-arbitrary positions. As the court put it: The very existence of rights under such plans depends on the degree of discretion lodged in the administrator. The broader that discretion, the less solid an entitlement the employee has and the more important it may be to him, therefore, to supplement his ERISA plan with other forms of insurance. …