Adam V. Russo | July 18, 2007

On June 18, 2007, the United States Supreme Court granted a writ of certiorari to hear the appeal of this Fourth Circuit case.  Their ruling will once again affect the application of ERISA.  Plaintiff (employee LaRue) alleged that the administrator had failed to invest his funds as instructed, resulting in a loss.  He sought monetary rewards, and both the District Court and Court of Appeals determined that the remedy he sought fell outside the scope of “equitable relief” § 1132(a)(3) of ERISA authorized. Money damages were the classic form of legal relief, absent from the list of equitable remedies available under § 1132(a)(3). Plaintiff could not recover under an equitable restitution theory since he did not allege that funds owed to him were in defendants’ possession but instead that the funds never materialized. (more…)

Category: 4th, ERISA, Fiduciary Liability, Third Party Administrators | No Comments »
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Adam V. Russo | July 18, 2007

The Tenth Circuit Court of Appeals held in Hollingshead v. Blue Cross Blue Shield of Oklahoma, 2007 WL 475832, 39 EBC (BNA) 2732 (10th Cir. 2007), that when a Plan states it will pay for only one organ transplant, the Plan may exclude charges incurred for the replacement of a previously transplanted organ that has failed. (more…)

Category: 10th, Summary Plan Description | No Comments »
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Adam V. Russo | July 18, 2007

The Southern District Court of Indiana held on February 8, 2007 in South Central Indiana School Trust v. Virginia Poyner, 2007 U.S. Dist. LEXIS 9368, that “in Sereboff, the Supreme Court held that Great-West did not apply to a situation where the third-party proceeds were segregated and hence “specifically identifiable.” Sereboff, 126 S.Ct. at 1874. Rather, such a claim for recovery was for enforcement of an equitable lien. Id. at 1874-75. And, going a step further, the Court said that where, as here, there is an equitable lien by agreement, there is no necessity that the funds even be specifically traced. Id. at 1875. According to the Court, the effort to recover such an agreed preexisting lien is equitable in nature.” (more…)

Category: 7th, Claims Procedures, Standings | No Comments »
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Adam V. Russo | July 18, 2007

Recently, the Eastern District Court of Michigan held in Citizens Insurance Company of America v. Pitney Bowes Software Systems Employee Medical & Health Care Service Corp., 2007 WL 713144 (E.D. Mich 2007) that where the Plan document excluded claims covered by automotive insurance in its claim exclusions section, and asserted a right to coordinate benefits with the same types of insurance, these provisions were contradictory and cancelled each other out.   This is why The Phia Group matches exclusion language with coordination of benefits and subrogation language, and advises the use of language interpretation provisions as well. (more…)

Category: 6th, Claims Procedures, Claims Review, Coordination of Benefits, Summary Plan Description | No Comments »
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Adam V. Russo | July 18, 2007

In Cheryl Street v. Ingalls Memorial Hospital, (2007 U.S. Dist. Lexis 18643), the Northern District Court of Illinois held on March 15, 2007 that just as a Plan must identify funds prior to seeking equitable relief in Federal Court, so too must relief sought by participants be specifically identifiable. In one case, decided by the Third Circuit Court of Appeals, a group of employee Plan Participants brought their Plan Administrator to court for handling their assets in an irresponsible manner. In Eichorn, et al. v. AT&T Corp., et al., 484 F.3d 644, (May 2, 2007), the Court held that while ERISA makes it illegal for a Plan Administrator to prevent the attainment of rights provided by the Plan, actions that lessen the value of the rights are not so prohibited. As such, in a case like this one, the only relief available was in the form of monetary awards and back pay, which is not “equitable relief” for purposes of Federal jurisdiction. (more…)

Category: 3rd, 6th, 7th, Claims Procedures, Claims Review, Coordination of Benefits, ERISA, Provider Reimbursement, Third Party Administrators | No Comments »
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