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Ninth Circuit Denies Health Care Providers’ ERISA Claims

The Ninth Circuit affirmed two district court judgments dismissing ERISA actions brought by health care providers in DB Healthcare v. Blue Cross Blue Shield of Arizona, No. 14-16518, and Advanced Women’s Health Center v. Anthem Blue Cross Life & Health Insurance Co., No. 14-16612. The health care providers’ argument was two-fold:  (1) health care providers … Continue Reading

Internal quality assurance discussion about $100,000 error in plan interpretation not evidence of conflict

Running an employee benefit claims operation is a complex undertaking, which requires continual training and oversight. A robust quality assurance organization can play an important part in the overall management mix. Curran v. Aetna Life Ins. Co., 13-cv-289, 2016 WL 3843085 (S.D.N.Y. July 11, 2016), gives a concrete example of a quality assurance review catching … Continue Reading

Second Circuit rejects “substantial compliance” rule

In Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016), the Second Circuit made a significant change to the impact of ERISA claim regulations on subsequent litigation, rejecting the rule that it is sufficient for claim administrators to substantially comply with the regulations. Instead, the court held that, unless there is strict compliance … Continue Reading

Another SCOTUS subrogation decision, and another deep dive into equity treatises

There is a lot about ERISA litigation that is hard to understand, but perhaps the most opaque issue is subrogation, which is the law governing when and how plans can recover benefits from participants. It seems that the Supreme Court is constantly changing the rules (while denying that it’s changing the rules), based on its … Continue Reading

ERISA preempts state-required “all payer claim databases” (APCD)

About twenty states, including Vermont, have passed laws requiring all entities that provide health care services to report information to a state agency; these are called “all payer claims databases” or APCDs. Though they may have many purposes, they all generally are intended to enforce a universal and consistent (within the particular state, at least) … Continue Reading

Preferred provider agreements do not support ERISA claim

In Penn. Chiro. Assoc. v. Independence Hosp. Indem. Plan, Inc., — F.3d –, 2015 WL 5853690 (7th Cir., Oct. 1, 2015), two chiropractors who had signed preferred provider agreements with an insurer claimed that the insurer violated ERISA in determining payments to them. In particular, plaintiffs claimed that the insurer had improperly recouped overpayments without … Continue Reading

Ninth Circuit judge calls for en banc review to overturn Providence Health v. McDowell

In Oregon Teamster Employers Trust v. Hillsboro Garbage Disposal, Inc., 800 F.3d 1151 (9th Cir. 2015), the corporate defendant, Hillsboro Garbage entered into contracts with a union health plan that provided coverage for Hillsboro’s union and non-union employees. Beginning in 2003, the union received contributions for the two individual defendants, who purportedly worked for Hillsboro, … Continue Reading

Third Circuit Rules That Assignment of Plan Benefits Confers Standing to Sue

In North Jersey Brain & Spine Ctr. v. Aetna, Inc., — F.3d –, 2015 WL 5295125 (3d Cir. Sep. 11, 2015), the court addressed the question “whether a patient’s explicit assignment of payment of insurance benefits to her healthcare provider, without direct reference to the right to file suit, is sufficient to give the provider … Continue Reading

Plan Manager Was Not a Fiduciary For Purposes of Subrogation Claim Standing

In Humana Health Plan, Inc. v. Nguyen, 785 F.3d 1023 (5th Cir. 2015), Humana entered into a Plan Management Agreement (“PMA”) with the API Enterprises Employee Benefits Plan. The PMA stated that API had the right to make all discretionary decisions about the plan’s administration and management. The PMA authorized Humana to provide “subrogation/recovery services” … Continue Reading

State Law Is Not A “Controlling Statute” Overriding Contractual Limitation

Heimeshoff v. Hartford Life & Acc. Ins. Co., 134 S. Ct. 529 (2013), held that a contractual limitation period in an ERISA plan is enforceable as written unless the period is unreasonably short, or a “controlling statute prevents the limitations provisions from taking effect.” In Heimeshoff, there was no dispute that the contractual limitation provision … Continue Reading

Three Strikes and You’re Out: Health Plan’s Decision Was Arbitrary and Capricious Be-cause It Repeatedly Refused To Abide By Remand Orders

In Butler v. United Healthcare of Tennessee, Inc., — F.3d –, 2014 WL 4116478 (6th Cir. Aug. 22, 2014), the court addressed what appeared to be a relatively straightforward health care benefit question, complicated by what the court described as a severely recalcitrant claim administrator.… Continue Reading

Plan’s Equitable Lien Not Defeated By Argument That State Law Precluded Participant from Recovering Medical Expenses from Tortfeasor

In Bd. of Trustees of the Nat. Elevator Indus. Health Benefit Plan v. McLaughlin,  — F.3d –, 2014 WL 4852096 (3d Cir. Oct. 1, 2014), plaintiff argued that his medical plan could not enforce an equitable lien by agreement to recover medical expenses paid because the New Jersey Collateral Source Statute (the “NJCSS”) precluded him … Continue Reading

Fifth and Sixth Circuits Consider Coordination-of-Benefits Remedies For ERISA Plans

Providing for “coordination of benefits” means including a provision in an insurance policy that address what should happen if more than one insurer covers the same claim. Virtually every primary insurance policy will say that, if other insurance exists, the other policy will pay first. Of course, when there are two policies providing coverage, each … Continue Reading

Fifth Circuit Ends “Texas Shell Game,” Holding that Plan Has an Equitable Remedy for Reimbursement

In a post from last year, I reported on how the Fifth Circuit had issued a decision In ACS Recovery Servs., Inc. v. Griffin, 676 F.3d 512, 514 (5th Cir. 2012), in which it held that an ERISA plan beneficiary and his lawyer had created a perfect settlement structure in which no one ever had … Continue Reading

Vesting of Employee Welfare Benefits – Who Knew It Was So Complicated?

One of the great things about writing this blog is learning something new. I sometimes fall into the trap of determining the law on a particular issue in the circuit in which I practice most (the Second), and assume that other circuits are the same. Sometimes, though, it turns out that one circuit is not … Continue Reading

Including Ambiguous Plan Language Verbatim In the SPD Can Effectively Eliminate Discretion to Interpret It — At Least in the Fifth Circuit

In Koehler v. Aetna Health, Inc., 683 F.3d 182 (5th Cir. 2012), the Fifth Circuit criticized a health insurer for having an SPD that mirrored the plan, and held that Cigna v. Amara did not prevent the terms of the SPD from impacting plan interpretation. The plaintiff, a participant in an HMO, suffered from sleep … Continue Reading

The Texas Shell Game – A Subrogation Story

An ERISA Plan Administrator’s subrogation rights are not the easiest thing in the world to determine. I’m not talking about the situation where the plan is making current payments to the beneficiary and wants to offset some prior liability or overpayment. That’s easy. What is complicated is when the plan has made a full payment, … Continue Reading
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