Adam V. Russo | July 31, 2009
by Greg Hitt and Naftali Bendavid, The Wall Street Jornal, www.wsj.com
WASHINGTON — Senior House Democrats, seeking a health bill acceptable to rank-and-file lawmakers, are warming to a plan to tax insurers that sell high-end health policies. (more…)
Adam V. Russo | July 31, 2009
by Ezra Klein, The Washington Post, www.washingtonpost.com
The central problem in health-care reform is that good policy and good politics point in opposite directions. Good policy proceeds from the understanding that our health-care system is a fractured, pricey, inefficient mess. Good politics, however, proceeds from the insight that a lot of people rely on this fractured, pricey, inefficient mess and don’t trust Washington to change it. Good politics means, as Barack Obama frequently says, that if you like what you have, you get to keep it. But put those imperatives together and you have a strange problem indeed: How do you reform a system that you’re not allowed to change? (more…)
Adam V. Russo | July 31, 2009
by Robert Weisman, The Boston Globe, www.boston.com
If you want to know how the proposed overhaul of the US healthcare system may play out nationally, talk to top executives at the biggest medical and life sciences companies in Massachusetts. (more…)
Adam V. Russo | July 31, 2009
SIIA, www.siia.org
Senate Finance Committee Nearing Agreement
A team of 6 bi-partisan Members of the Senate Finance Committee are close to reaching agreement on a compromise healthcare reform package. Chairman Baucus’ goal from the start of this process was to introduce a package that was bi-partisan and could garner the 60 votes necessary to pass out of the Senate. The Committee has spent time meeting with various interested parties (including SIIA) and continues to develop cost cutting measures. (more…)
Adam V. Russo | July 29, 2009
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.
by Emily Berry, American Medical News, www.amednews.com
The Tennessee Medical Assn. has filed a lawsuit against a collections company working in several states to take back reimbursements paid to doctors. The lawsuit alleges fraud and asks a state court to block the company from trying to collect any more money from physicians. (more…)
Adam V. Russo | July 29, 2009
by Andrea Jackson, Times-News, www.magicvalley.com
A Twin Falls lawyer is fighting a lawsuit slapped against him by a former client claiming negligence, and has filed paperwork to dismiss the case in Twin Falls 5th District Court.
William Hollifield, of the Hollifield Law Office in Twin Falls, is being sued by Amanda Fomichev, a former client who hired him as a personal injury lawyer after she lost a leg when she was hit by a vehicle while working as a car wash attendant almost four years ago at Lynch Oil Inc.’s Mr. Wash. (more…)
Adam V. Russo | July 29, 2009
by Benjamin Glass, www.AnAmericaDay.com
After seeing the injustices suffered by tort plaintiffs in other jurisdictions, the state of Texas passed a law designed to compensate people who had been injured by healthcare decisions made by their insurance companies. The Texas law sought to hold HMOs liable when their decisions to deny coverage caused further damage to their customers. So when two Texans were denied coverage after their HMO failed to use ordinary care in making coverage decisions, they sued under the new law. (more…)
Adam V. Russo | July 29, 2009
by Kate O’Sullivan, www.CFO.com
Plans can no longer require higher co-pays, higher deductibles, or lower lifetime or annual dollar limits for mental health than for physical and surgical coverage.
Since provisions of the new mental-health-parity law apply to benefit-plan years beginning in January 2010, companies should assess their benefits this summer and make the necessary adjustments in time for fall open-enrollment periods, experts suggest. (more…)
Adam V. Russo | July 29, 2009
by B. Janell Grenier, The Fiduciary Guidebook, www.fiduciaryguidebook.com
One of the key aspects of determining whether ERISA fiduciary law applies has to do with whether the benefit plan at issue is an ERISA-covered plan. ERISA provides an exemption from its applicability under 29 C.F.R. Section 2510.3-1(j) for certain “group or group-type insurance programs.” If a plan meets all four requirements of this exemption, then the plan is not an ERISA-covered plan, but will be governed by state law. (more…)
Adam V. Russo | July 29, 2009
by Jerry Geisel, Business Insurance Magazine, www.businessinsurance.com
WASHINGTON-Some may wonder why health care reform legislation contains a provision that would eliminate the ability of employees with flexible spending accounts, health reimbursement arrangements and health savings accounts to use them to pay for over-the-counter medications. (more…)
Adam V. Russo | July 29, 2009
Administration’s bill would give Treasury monitoring powers
by Mark A. Hofmann, Business Insurance Magazine, www.businessinsurance.com
WASHINGTON-Supporters of a federal Office of National Insurance hope the Obama administration’s call for such an entity within its broader financial services regulatory reform proposal will help them realize their goal. (more…)
Adam V. Russo | July 28, 2009
In Wenner v. Sun Life Assurance Co. of Canada, 482 F.3d 878 (6th Cir. 2007), the Sixth Circuit found that Sun Life’s failure to give plaintiff an opportunity to appeal the new grounds for its termination of his benefits violated ERISA’s notice requirements. The insurer initially terminated plaintiff’s benefits because he failed to provide requested medical information; on appeal, it upheld its decision on entirely different grounds. The court held that Sun Life failed to provide a full and fair review of the decision denying the claim, as required by ERISA, when it refused to allow plaintiff a second appeal. In considering the appropriate remedy, the court reasoned that because Sun Life previously determined plaintiff was entitled to benefits, he should not be denied those benefits until his insurer complied with ERISA. Accordingly, the court affirmed the reinstatement of plaintiff’s benefits.
Adam V. Russo | July 28, 2009
In Administrative Committee of the Wal-Mart Stores, Inc. v. Gamboa, 479 F.3d 538 (8th Cir. 2007), an ERISA plan administrator brought suit seeking equitable reimbursement from a plan participant who had received a settlement from a tortfeasor. Although the reimbursement provision was contained in an SPD for a health plan, the employer had no formal written health plan. Reversing summary judgment for the participant, the Eighth Circuit held that the plan administrator reasonably construed the SPD to be on the plan document for purposes of a group health plan in the absence of any formal plan and that the reimbursement provision in the SPD was therefore enforceable. (more…)
Adam V. Russo | July 28, 2009
In Daic v. Metropolitan Life Insurance Co., 458 F. Supp. 2d 1167 (D. Haw. 2006) the district court rejected each of plaintiff’s arguments challenging the validity of the plan’s reservation of discretionary authority. The court concluded that the plan’s discretionary language was clear and found it inconsequential that such language was in the certificate was delivered to the insured. The court also held that the insurer did not have to delegate its fiduciary responsibilities to a third party to preserve its discretionary authority and found that the insurer’s inherent conflict of interest was merely a factor to be considered in applying the abuse of discretion standard of review. Finally, the court held that the state insurance commissioner’s memorandum, although purporting to state that a discretionary clause was “deceptive” and “was not to be used in health insurance contracts or plans,” had no legal effect as it did not purport to retroactively invalidate such clauses and provided for no private right of action.
Adam V. Russo | July 28, 2009
In MacLeod v. Proctor & Gamble Disability Benefit Plan, 460 F. Supp. 2d 340 (D. Conn. 2006) the administrator denied the participant’s application for benefits on the grounds that the claimed disability resulted from the participant’s prior military service and therefore was excluded from coverage. At oral argument, the administrator admitted that its decision was based on the “categorical military exclusion” and did not entail an individualized consideration of the particular facts of the application. The plan at issue, however, specifically provided that in the event of an “illness, accident or injury occurs while the Participant is working for pay for some person or organization other than the Company, payment of benefits under the Plan shall be made only at the discretion of the [administrator] after their review of the facts of the case.” Although the court did not find that the administrator’s conclusion that the participant’s disability occurred during his time in the military was arbitrary and capricious, it concluded that the manner in which the administrator evaluated the claim was an unreasonable interpretation of the plan language and remanded the matter.
