Adam V. Russo | April 4, 2007

In this case, an employee of a company with a self funded ERISA plan was receiving benefits due to her disabled status. The TPA hired a physician to re-examine the employee, and based on her diagnosis, terminated benefits. The physician determined that the employee could perform sedentary work, which meant she was no longer “disabled” in accordance with the terms of the plan. The TPA had, after the physician’s diagnosis was complete, obtained two more evaluations. The three tests (IME, Functional Capacity Evaluation, and Employability Assessment) were all performed by different parties, and all supported the plan’s decision. The employee, meanwhile, did not argue that the tests should be ignored, and instead presented a letter from her treating physician, diagnosing her as disabled, but lacking an explanation or evidence to support the designation. Upon review, the court found in the plan’s favor. (more…)

Category: ERISA, Litigation, Plan Language, Standings, Third Party Administrators | No Comments »
Tags:

Adam V. Russo | April 4, 2007

Recently, in the state of Washington, a law was passed that prohibits workplace discrimination based upon sexual orientation. When an employee protested the denial of health care coverage to her partner by her employer’s self funded ERISA plan, she brought the matter to court. The court in turn determined that the law could not be enforced against private employers with self funded plans, as it conflicted with ERISA. (more…)

Category: 4th, ERISA, Maryland, Preemption, Washington | No Comments »
Tags:

Adam V. Russo | April 4, 2007

An employee left her job due to carpal tunnel syndrome. She began receiving benefits under her employer’s self funded ERISA plan. The syndrome became worse, and the employee underwent surgery. She exhausted her short term benefits and applied for long term benefits under the same plan. The plan denied the benefits, and the employee sued. The court applied a de novo standard of review, meaning it examined the evidence from an entirely objective perspective seeking to determine if a reasonable trier of fact would find one way or the other. (more…)

Category: ERISA, Litigation, Plan Language, Summary Plan Description | No Comments »
Tags:

Adam V. Russo | April 4, 2007

The Delaware State Supreme Court recently upheld the dismissal of a lawsuit, filed against the tobacco industry, by the foreign governments of Panama and Sao Paulo, Brazil. The nations argued that they had lost money in the treatment of citizens suffering from tobacco use complications. Ordinarily, governments, employers, and other organizations subrogate – meaning they step into the shoes of the person actually suffering as a result of the tobacco use – and pursue the responsible party in the victim’s name. In this case, the plaintiffs instead chose to (unwisely) sue tobacco companies directly. Subrogation works because the person who bought, used, and suffered due to the tobacco use has the claim. The plaintiffs in this case, however, tried to file a claim directly against parties they had never had direct dealings with, and failed. (more…)

Category: Claims Procedures, Delaware, Subrogation | No Comments »
Tags:

Adam V. Russo | April 4, 2007

In March of 2005, Poyner was injured when an automobile struck her while she was riding her bicycle and received nearly $ 200,000.00 in medical benefits. Subsequently she recovered $ 10,000.00 from the insurer of the automobile which struck her and $100,000.00 from her own under insured motorist coverage. The Plan attempted to persuade Poyner to abide by the terms of the benefit plan, which required her to pay the Plan the $110,000.00 she collected from the two insurance policies. Poyner asserted that ERISA prohibits anything other than an equitable remedy in such a situation and the Trust’s claim was one for money, not an equitable remedy. (more…)

Category: ERISA, Litigation, Provider Reimbursement, Standings | No Comments »
Tags:

Adam V. Russo | April 4, 2007

This case arose from a Plan’s failure to add an employee’s dependents to an ERISA welfare benefit plan. As a benefit of employment, the employer offered its employees health insurance. Under the Plan, the employer was both a “participant” and the “Plan Administrator.” Employees were instructed to direct their inquiries about the Plan to their employer, which acted as the general intermediary between its employees and the Insurer. (more…)

Category: Claims Procedures, ERISA, Fiduciary Liability, Plan Language, Standings, Third Party Administrators | No Comments »
Tags:

Adam V. Russo | April 4, 2007

In this case, a TPA was sued by their clients (employers and those employer’s employees), for mishandling their plans’ funds. The TPA trustees in turn hoped to sue their attorney, claiming that their attorney should have notified them of the fund management issues and improper expenditures. The court found that the attorney did not have discretionary control over the assets of the plan, access to funds, or powers to administer the plans, and was therefore not a fiduciary. Even if the attorney knew of the transactions and failed to disclose them, the fund trustees would be unable to demonstrate how the attorney’s actions or lack of action proximately caused the mismanagement of the funds. (more…)

Category: ERISA, Fiduciary Liability, Third Party Administrators | No Comments »
Tags:

Adam V. Russo | April 4, 2007

In this case, an employee stopped working due to a medical condition and began receiving disability benefits from her employer’s self funded ERISA plan. After two years the case was reassessed, the TPA terminated the benefits. The insured filed suit against the TPA, seeking both payment of past claims and re-instatement of future benefits. The TPA moved to dismiss arguing that it was not a proper defendant in this case because it did not have any financial responsibility to the employee. The employer and plan, the TPA asserted, were the proper defendants. The court denied the motion to dismiss, however, stating that the TPA’s discretionary power over the payment of claims made it a fiduciary to the plan and plan members. (more…)

Category: Claims Procedures, Claims Review, Coordination of Benefits, ERISA, Fiduciary Liability, Third Party Administrators | No Comments »
Tags:

Adam V. Russo | April 4, 2007

Section 502(a)(3)(B) of ERISA permits a fiduciary to bring a civil action “to obtain equitable relief to enforce the terms of the plan”. To obtain this “equitable relief,” the basis for the fiduciary’s claim and the relief it seeks must be equitable in nature. Importantly, a fiduciary cannot seek to impose personal liability, as that would be a legal remedy. The Policy in this case required repayment of an overpayment of benefits that resulted when a claimant received benefits in the amount of $ 19,612. The Plan requested reimbursement and the beneficiary refused, stating that she no longer had any of the funds. (more…)

Category: Claims Procedures, ERISA, Federal Circuits, Fiduciary Liability, Provider Reimbursement, Standings | No Comments »
Tags: