Latest Entries

Diamond Crystal Brands, Inc. v. Wallace, 531 F.Supp.2d 1366 (N.D. Ga.2008)

After the negligent medical care and consequential death of Deborah Hayes, the Estate and her daughter Tamara Hayes pursued a wrongful death claim against the hospital.  In Georgia State Court plaintiffs settled for $900,000, of which $837,000 went to Tamara Hayes and $63,000 to the Estate of Deborah Hayes.

Prior to Deborah Hayes’s death, her employer, Diamond Crystal provided $261,863.58 in medical benefits related to the medical malpractice.  After the settlement, Diamond Crystal sought reimbursement of claims paid. Read more

In the matter of Sgro v. Danone Waters of North America, Inc., 2008 U.S. App. LEXIS 13973 (9th Cir. Jul. 2, 2008), an employee - Mitchell Sgro - applied for benefits from his employer’s ERISA Plan.  He incurred $412.00 in copying fees, in the process of supplying documentation and medical records to his employer as part of his claim. Read more

You may have heard some grumbling about the recent case of Amschwand v. Spherion Corp., 2007 U.S. App. LEXIS 24435 (5th Cir. 2007).  The facts of the case are as follows:

Thomas Amschwand was a participant in his employer’s ERISA benefits plan, which included life insurance benefits.  The employer switched insurers after Thomas Amschwand was diagnosed with cancer. The new policy would not cover an employee unless and until that employee had worked one full day (post plan swap).  According to the Amschwand’s attorney, they were never advised of the requirement.  Unfortunately, Mr. Amschwand died without ever having worked a day after the employer had changed insurers. Read more

by Ron E. Peck, Esq.

The matter of administrative discretionary authority, when administering a health benefits plan within the purview of ERISA, and the deference federal courts must show to such discretion, has been the new hot topic in ERISA ever since subrogation rights were affirmed by the Sereboff case.  The Supreme Court first stated that health plan administrators, who assert discretionary authority to administer a plan within the plan’s document, are due deference in Firestone Tire and Rubber Co. v. Bruch.  Afterward, federal courts could overturn administrator benefit determinations only if they find that the administrator has abused its discretion (an arbitrary and capricious standard of review). Read more

As found in multiple cases in Oklahoma, an insured who quickly settles with a liable third party (tort-feasor) will eliminate any and all opportunities for its UIM carrier to subrogate or seek reimbursement for paid claims, against third party policy limits.  Read more

Many involved in the administration of ERISA Plans do not realize that some state insurance law is preempted even when a fully insured ERISA Plan is involved.

In Spellman  v. United Parcel Service, 540 F. Supp.2d 237 (D.C. Maine 2008), the Court addressed an issue of enforcing Maine’s  workers’ compensation statutes with regards to health plans under ERISA. Read more

Shelby County Healthcare Corp, d/b/a Regional Medical Center v. The Majestic Star Casino, LLC group Health Benefit Plan, 2008 WL 782642 (WD Tenn.) has demonstrated that even though the SPD gives the Plan the final decision to accept or deny medical claims, discretion does not apply to the Plan’s TPA.Damon Weatherspoon, a plan participant of the Majestic Star Casino LLC Group Health Benefit Plan was involved in a single vehicle accident and sustained over $400,000 in medical expenses at the Regional Medical Center.  Reports indicated that Weatherspoon had violated Mississippi law by driving under the influence, driving without a valid Mississippi driver’s license and driving without insurance. Read more

U.S. District court Judge Harold Baer has ruled that Allianz S.E. is primarily entitled to recoveries from third parties found liable for damages from the Sept.11, 2001 terrorist attacks.  World Trade Center leaseholder Silverstein Properties Inc. challenged the ruling claiming that the $433 million settlement of the $3.55 billion property limit from Allianz S.E. last year was insufficient.  Read more

A vast difference between the two Presidential candidates is the role of the U.S. government providing health insurance coverage.

Senator Obama promotes a national policy that supports individuals and small employers.  Obama would rely much more on government mandates in which income based federal funding would be provided to help assure expansion on coverage.  In this plan, employers would have to either provide health insurance coverage to its employees or pay into a national plan that would be available to individuals not covered by employee plans.  Regardless of which direction would choose, they would also benefit from a new federal health reinsurance program in which the government would take on liability for catastrophic loss in health care claims. Read more

California

The California Assembly Health Committee recently passed a series of bills that will mandate expansion of specific benefits and health services for insurers. Benefits and services include mental health coverage (AB1877), screening and diagnostic test for gynecological cancer (AB1774), HIV testing (AB1894), maternity health care (AB1962), and breast cancer screening (AB 2234).  Insurance plans opposing bills argue that e increasing costs of the proposed mandates would total an estimated $2.7 billion annually and that 85,000 Californians would lose health insurance coverage because of the consequential higher premium costs. Read more