Adam V. Russo | November 28, 2007
There is a recent newsworthy item that I wish to discuss, as it is pertinent to our industry. The November 20, 2007 Wall Street Journal featured an extremely negative cover story, relating to the self-insured industry’s subrogation activities under ERISA. These types of prominent news stories do nothing for the self-insured industry except motivate the public to change current ERISA legislation. For those of you who do not know about this case, the story covers a woman’s collision with a semi-trailer truck seven years ago, leaving the 52-year-old Deborah Shank permanently brain-damaged and in a wheelchair. Her husband, Jim, received a $700,000 accident settlement from the trucking company involved. After legal fees and other expenses, the remaining $417,000 was put in a special trust to be used for Mrs. Shank’s care. (more…)
Category: Claims Procedures, Claims Review, ERISA, Litigation, News, Provider Reimbursement, Signed Subrogation Agreements, Standings, Subrogation, Summary Plan Description, Third Party Administrators |
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Adam V. Russo | November 13, 2007
On September 25, 2007, a Federal District Court in New Jersey held in Mulholland v. UFCW Local 1776 Participating Employers Health and Welfare Fund, 2007 WL 2814648 (DNJ) that the purchase of stop loss insurance does not preclude self-funded ERISA status. The court went on to say that because self-funded plans can come close to becoming a fully insured plan, the question is not whether a self-funded plan has reinsurance, but rather, how high is their specific deductible. In other words, does the self-funded plan retain considerable risk of loss, or, does the Plan purchase an excessive amount of stop-loss insurance? (more…)
Category: Claims Procedures, ERISA, Litigation, New Jersey, Provider Reimbursement, Stop Loss, Third Party Administrators |
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Adam V. Russo | November 13, 2007
The United States District Court for the Eastern District of Texas recently presided over a case involving a plan’s denial of claims due to a lack of signed subrogation agreement. Don Burgett, Et. Al. v. MEBA Medical and Benefits Plan, 2007 U.S. Dist. LEXIS 70934, (September 25, 2007). The Plan in this case lost, and the court determined the Plan’s conditioning payment of claims on the signing of a subrogation agreement was not supported by the summary plan document (“SPD”). The court held that the language of the SPD controls and additional agreements cannot create new rights for the Plan. (more…)
Category: 5th, Claims Procedures, Plan Language, Provider Reimbursement, Signed Subrogation Agreements, Subrogation, Summary Plan Description |
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Adam V. Russo | November 13, 2007
The Texas Made-Whole Rule, adopted in Ortiz v. Great Southern Fire & Casualty Insurance Co., no longer applies to cases where the Plan disclaims the rule and requires full reimbursement in the plan document. 597 S.W.2d 342, (Tex. 1980). In the Ortiz case the insurance carrier relied upon arguments made in equity. The court held that health plans do not have an equitable right to recovery until the plan beneficiary is fully compensated. Id. (more…)
Category: Attorneys' Fees, ERISA, Made Whole Rule, Plan Language, Provider Reimbursement, Summary Plan Description, Texas |
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Adam V. Russo | November 13, 2007
In the case of Bauhaus USA, Inc. v. Lillie Regina Holmes Copeland, et. al., 2007 Miss. LEXIS 545 (September 27, 2007), a self-funded Plan coming under the purview of ERISA sought reimbursement of claims it had paid on behalf of a minor child. The court took possession of funds in order to create a trust and use the funds to protect the minor. (more…)
Category: ERISA, Minor's Compromise, Mississippi, Preemption, Provider Reimbursement, Standings |
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