Latest Entries

South Dakota Senate seeks to graft “made whole” into each and every subrogation provision which insurers seek to enforce in the state. The legislature in South Dakota is attempting to amend Title 58-11 of the Insurance Code by adding the following new section: Read more

Mental health and substance abuse care can’t be handled differently from medical and surgical treatment, according to the new rules. Also, employee assistance programs cannot serve as mental health care gatekeepers, benefit experts say.

Employers would no longer be permitted to require separate deductibles for mental health and medical treatment under new proposed parity rules issued last week by the departments of Health and Human Services, Labor and the Treasury. Read more

By ROBERT PEAR – The New York Times

WASHINGTON — The Obama administration issued new rules on Friday that promise to improve insurance coverage of mental health care for more than 140 million people insured through their jobs.

In general, under the rules, employers and group health plans cannot provide less coverage for mental health care than for the treatment of physical conditions like cancer and heart disease. Read more

The U.S. Departments of Labor, Health and Human Services (HHS), and the Treasury have jointly issued new rules providing parity for consumers enrolled in group health plans who need treatment for mental health or substance use disorders.

The new rules prohibit group health insurance plans — typically offered by employers — from restricting access to care by limiting benefits and requiring higher patient costs than those that apply to general medical or surgical benefits. The rules implement the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Read more

House Set to Formally Consider Partial Repeal of McCarran-Ferguson

SIIA’s Government Relations Staff has learned that the House will most likely vote on legislation next week that would partially repeal McCarran-Ferguson. The bill, HR-3596, the Health Industry Anti-Trust Enforcement Act, seeks to prohibit issuers of health and/or medical malpractice insurance from engaging in any form of price fixing, bid rigging, or market allocations in connection with providing health insurance coverage or coverage for medical malpractice claims or actions. The bill also authorizes the Federal government the ability to prosecute any prohibited actions under anti-trust law. Read more

Subrogation rights are again in danger in Colorado with the introduction of H.B. 10-1168. This bill essentially undoes healthcare subrogation while codifying the “made whole” and “common fund” doctrines into law. The proposed bill will certainly have a devastating effect on healthcare, workers compensation and UM insurance subrogation, but other auto and property subrogation rights will also be greatly impacted whenever there is a personal injury suffered in the same loss. The most dramatic aspect of the proposed bill is that carriers cannot bring direct subrogation actions in such instances. Read more

February 1, 2010

(1) Discussions Continue on Comprehensive Health Reform as House Prepares to Act on Narrowly Focused Bills

Congressional leaders are considering options for moving forward with health reform legislation following President Obama’s State of the Union address last week in which he urged lawmakers to “come together and finish the job.” Read more

MyHealthGuide Source: Meredith Z. Maresca, BNA’s Pension & Benefits Daily, 1/27/2010, www.bna.com

In a decision addressing identification of the proper defendant in a benefit claim action brought pursuant to the ERISA’s civil enforcement provision, the U.S. District Court for the Southern District of Ohio held that the health plan’s TPA potentially could be liable for the alleged wrongful denial of benefits to cover a beneficiary’s bone cancer treatment. Read more

The Boeing Company v. Thurmon, No. 4:09-cv-1456, in the United States District Court for the Eastern District of Missouri, December 7, 2009. This is a subrogation case, significant for its fresh and express reiteration of the bedrock proposition that purchase of stop loss insurance by the sponsor of a self-insured employee benefit plan does not affect pre-emption analysis. In other words, a self-insured plan is still a self-insured plan, despite the existence of excess loss coverage. Read more

I received this from Dave Reynolds at Capitol.

Self Funding Article

January 22, 2010 (PLANSPONSOR.com) – A federal court has refused to dismiss a claim by a Jersey Construction employee that he was fired for pursuing health benefits for his wife’s chemotherapy.

The U.S. District Court for the District of New Jersey said it found that Christian Pailleret stated sufficient facts to support a prima facie case under § 510 of the Employee Retirement Income Security Act (ERISA). The court said Pailleret had no “smoking gun” evidence of intent, but the fact that almost immediately after he submitted medical claims of tens of thousands of dollars, he was assigned low-level and “degrading” tasks and shortly after that was terminated without notice or explanation was sufficient to show a plausible claim and “to thus unlock the doors of discovery.” Read more

Scaled-back bill seen as effort’s best chance

Jerry Geisel

WASHINGTON—Republican Scott Brown’s victory last week in the election to represent Massachusetts in the U.S. Senate has halted Democrats’ drive to pass sweeping health insurance reform.

The state senator came from behind in polls to win the U.S. Senate seat that Sen. Edward Kennedy held for 47 years until the Democrat’s death last August. Read more

By Andrea Davis

January 25, 2010

The U.S. Supreme Court heard arguments last week in a case that could have far-reaching implications for pension plan administrators and the way in which they interpret the terms of their plans.

“The justices were asking a lot of questions based on the particular facts of the case as opposed to the broader policy implications that this issue presents for all employers,” says Amy Covert, a partner in the labor and employment law department of Proskauer, who attended the session. Read more

This is a huge win for the subrogation industry.

The court held that Sereboff, rather than Knudson, controlled in this case. Like in Sereboff, the Plan targeted specific funds for recovery , Cusson’s LTD payments, and identified the specific portion to which Liberty is entitled— the amount of the overpayment while Cusson was receiving benefits under the LTD Plan. Read more

The Supreme Court has agreed to decide whether the attorney’s fees provision in the Employee Retirement Income Security Act (ERISA) permits courts to award such fees to prevailing parties only. In Hardt v. Reliance Standard Life Ins. Co. (No. 09-448), the Fourth Circuit, in an unpublished opinion, held that an employee who filed a claim in district court alleging that her denial of long-term disability benefits was unlawful was not entitled to an award of attorney’s fees. The lower court had agreed with the claimant and remanded the matter back to the insurance underwriter for reconsideration, which eventually granted her the benefits sought. Read more