Archives: Insurance Benefits

Subscribe to Insurance Benefits RSS Feed

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

Sixth Circuit criticizes administrator for not allowing treating doctors more time to return calls

Shaw v. AT&T Umbrella Ben. Plan No. 1, 795 F.3d 538 (6th Cir. 2015) concerned denial of plaintiff’s claim for disability due to chronic neck pain. The district court affirmed the denial, but the 6th Circuit reversed, finding the determination arbitrary and capricious. The court took issue with much of the claim administration, criticizing the … 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

First Circuit Applies Younger abstention doctrine to ERISA preemption claim

In Sirva Relocation, LLC v. Richie, 794 F.3d 185 (1st Cir. 2015), ERISA preemption met federal abstention, and lost. Knight was an employee of Sirva, which had a disability plan insured by Aetna. Knight received 24 months of disability benefits, which were then terminated under a mental illness limitation; he responded by filing a discrimination … 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

Death Resulting From DVT Caused By Long Flights Not Covered Under AD&D Policy

Williams v. Natl. Union Fire Ins. Co. of Pitt., 2015 WL 4080909 (9th Cir. July 7, 2015) involved the death of “an acclaimed horticulturist” from pulmonary embolism triggered by deep vein thrombosis after flying approximately 28 hours over five days. Plaintiff was covered by an AD&D policy through his employer. The policy covered death as … Continue Reading

Failure to Understand Exhaustion Requirement Does Not Excuse Compliance

Orr v. Assurant Employee Benefits, 786 F.3d 596 (7th Cir. 2015), concerned the failure to exhaust administrative remedies following the denial of a claim for AD&D benefits. The plan in question required two administrative appeals; the administrator advised plaintiffs of these two appeals, and specifically stated that the failure to complete both reviews could result … 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

Sixth Circuit At it Again: Orders Make-Whole Relief in Disability Benefit Claim

In Stiso v. Intl. Steel Group, 2015 WL 3555917 (6th Cir. June 9, 2015), the court reversed a ruling by the district court that dismissed a claim for make-whole relief, and directed the district court “to grant an equitable remedy [against the employer and insurer] equivalent to the promised increase in benefits to plaintiff.” The … Continue Reading

ERISA Claim Accrues Upon Clear Repudiation of Claim, Even if There is No Formal Denial Letter

In Witt v. Metro. Life Ins. Co., 772 F.3d 1269 (11th Cir. 2014), the court answered the question: “what happens when the defendant says it issued a formal denial letter and the plaintiff says he never received the letter, but it is undisputed the defendant terminated benefits and did not pay the plaintiff any benefits … Continue Reading

Beneficiary Designation Forms Are not Plan Documents; Change of Beneficiary By Phone Was Sufficient

In Becker v. Williams, — F.3d –, 2015 WL 348872 (9th Cir. Jan. 28, 2015), the plan participant called the plan administrator to change the beneficiary of his pension plans from his ex-wife to his son. His employer sent him beneficiary change forms, but he never completed them in the years before he died. After … Continue Reading

Eighth Circuit Enforces Choice of Law Clause; Discusses Test for Evaluating Reasonableness of Plan In-terpretation

In Brake v. Hutchinson Tech. Inc. Grp. Disability Income Ins. Plan, 774 F.3d 1193 (8th Cir. 2014), the court determined that, where a policy insuring a South Dakota resident was issued in Minnesota to a Minnesota employer, and provided that it was governed by Minnesota law, then a South Dakota regulation precluding discretionary clauses could … Continue Reading

Eighth Circuit Leaves Open Possibility That Procedural Irregularities Can Preclude Discretionary Review

In Johnson v. United of Omaha Life Ins. Co., 775 F.3d 983 (8th Cir. 2014), the court determined that the district court erroneously reviewed the administrator’s determination under the de novo standard, instead of the arbitrary and capricious standard. It ruled that it did not need to decide whether procedural irregularities still could result in … Continue Reading

Insurer Reasonably Denied AD&D Claim Following “Suicide By Cop”

In Rice v. ReliaStar Life Ins. Co., 770 F.3d 1122 (5th Cir. 2014), the police responded to a 911 call about the decedent, Rice, sitting in his car, in his garage, with a gun to his head, threatening suicide. After various failed efforts by the police to get him to surrender, he walked toward the … Continue Reading

Court Provides Narrow Interpretation for Mental Illness Limitation

In George v. Reliance Standard Life Ins. Co., 776 F.3d 349 (5th Cir. 2015), a case of first impression, a divided Fifth Circuit panel decided when a disability is “caused by or contributed to by” a mental illness. The plaintiff was a helicopter pilot who was disabled due to pain suffered at the site of … 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
LexBlog