Understanding Employee Benefits and key developments in the employee benefits field and items of interest to our clients. MORE

Employers know that since the 1980s they have been required to check the lawful work status of employees that they hire through the I-9 process. Employers also know that Immigration and Customs Enforcement (ICE) can audit their workplaces, as can the Department of Labor, and impose fines and other sanctions for failure to comply with those requirements. However, employers may not realize other collateral consequences that can occur if an undocumented employee is hired.

Our tale begins with an employee covered under a multiemployer health and welfare plan for health benefits. The employee enrolled his newborn twins under the plan. The twins, born in the United States and therefore citizens of the United States, were born prematurely and incurred substantial medical expenses, over $250,000 for one twin and $450,000 for the other. The self‑funded plan had a stop loss contract in place to cover large claims. The stop loss carrier investigated the claim and discovered that the employee had submitted an invalid Social Security number when hired and consequently might be illegally employed in the United States. The stop loss carrier then concluded that the employee was therefore not an “eligible employee” under the terms of the plan and denied coverage for the claim. Instead, the stop loss carrier refunded the $2,700 in premiums that the plan had paid for coverage for the employee and his family. Not surprisingly, a lawsuit ensued.

The parties filed motions for summary judgment. The stop loss carrier claimed that the employee was not eligible for coverage under the plan because he was not eligible to work in the United States. The plan claimed that the employer had received from the employee a facially valid permanent resident card which the employer believed made the employee eligible to work in the United States. The court concluded that the question was one of contract interpretation under federal and state (California) law. California has a statute that explicitly provides certain protections and benefits to employees who are undocumented. Based on that statute, the court found that the stop loss carrier could not deny benefits based solely on the undocumented status of the worker.

The case must still proceed to trial on various questions, including punitive damages and covenants of good faith. Thus, the case is not yet over.

Not all states have statutes like the California statute explicitly protecting undocumented workers. In addition, because the court’s analysis was largely based on the terms of the stop loss contract, stop loss carriers in the future may be able to deny benefits for undocumented workers by including such a limitation in their stop loss contracts. Employers who self-fund their plans and use stop loss contracts to protect themselves from high claims should carefully review those stop loss contracts for any inconsistencies between the plan provisions and the stop loss contracts. If a stop loss contract excludes claims that the plan otherwise covers, the employer may find itself truly self-insured for that claim.

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