Adam V. Russo | August 31, 2009
From The Bench – The Self-Insurer Volume 26* August 2009
By John H. Eggertsen, Esq. and Michael Friedman, Esq.
II. Fifth Circuit Rejects Benefit Decision For Procedural Defects; Can’t Even Assess If Determination was Arbitrary And Capricious
In Lafleur v. Louisiana Health Service Indemnity Company, d/b/a Blue Cross Blue Shield of La., 563 F.3d 148 (5th Cir. 2009), the Fifth Circuit found that Blue Cross Blue Shield of Louisiana (“BCBSL”) was so deficient in its substantive compliance with ERISA’s procedural regulations that it could not even express an opinion as to whether the determination was arbitrary and capricious. (more…)
Category: 5th, Louisiana, MetLife v. Glenn |
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Adam V. Russo | August 31, 2009
From The Bench – The Self-Insurer Volume 26* August 2009
By John H. Eggertsen, Esq. and Michael Friedman, Esq.
After the U.S. Supreme Court’s recent decision in Metropolitan Life Ins. Co. v. Glenn ___ U.S.___, 128 S. Ct. 2343 (2008), many circuit courts have been applying a magnifying glass to their prior standard of review decisions, and making whatever adjustments they feel are necessary in light of this most recent guidance. We have discussed some of those cases in the past, and may do so again if circumstances warrant. In this discussion, however, we turn to a notable trend that had been emerging pre-Glenn, is continuing unabated and may be accelerating post-Glenn – that trend is the tendency of the courts to examine in greater detail the actual evidence on which claims determinations are based and the administrators’ rationales for making their determinations based on that evidence. Even under an arbitrary and capricious standard of review, generally held to be the most deferential standard, the courts are more willing to take the administrators’ word at face value. In addition, courts are scrutinizing claim determinations with an eye towards ERISA’s procedural requirements, and striking down those that fail to comply. The two cases discussed here are clear evidence of both these trends. (more…)
Category: 6th, MetLife v. Glenn, Ohio |
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Adam V. Russo | August 31, 2009
System Covering 160 Million Threatened by House Bill SIIA Cites 10 Impacts on Employer-Based Health Plans
August 31, 2009 — The Self-Insurance Institute of America, Inc. (SIIA) today identified 10 threats to the employer-based healthcare system in “The Americans Affordable Health Choices Act” (HR 3200), which has been approved by three House committees and apparently is headed toward floor debate when Congress reconvenes. (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 28, 2009
Health-care reform advocates say Massachusetts proves it can be done. But the results are mixed.
The Week Aug. 25- Sept.4, 2009
Briefing•Thursday, August 20, 2009
How does the state’s health plan work?
In an effort to achieve universal coverage, Massachusetts essentially requires every resident to obtain health insurance-either through their employer, a private plan, or, for low-income residents, a subsidized state program. Those who don’t get insurance are fined about $1,000 a year, largely levied through the state income tax. Businesses with more than 11 employees must offer health insurance to their workers or pay annual fines of $295 per employee. This strategy, known as employer and individual mandates, also forms the backbone of reform bills making their way through Congress. The state, which enacted the reform in 2006, also created a fund to subsidize insurance for those who can’t afford it. Unlike the “public option” that has been pushed by President Obama and many congressional Democrats, this is not a separate government insurance plan, but a fund that pays for private insurance. (more…)
Category: Health Care Legislation, Massachusetts |
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Adam V. Russo | August 28, 2009
August 21, 2009
On August 19, 2009, the U.S. Department of Health and Human Services (“HHS”) posted an “advance copy” of its final HIPAA breach notification regulations on the HHS website. These regulations are expected to be published in the Federal Register on August 24, 2009. Once published, covered entities and business associates will, as a practical matter, only have 30 days to comply with the new rules-a very short time and one which will force them to work very diligently to comply with the new rules. (more…)
Category: HIPAA |
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Adam V. Russo | August 28, 2009
Authors Gina M. Kastel & Maureen M. Maly
On August 19, 2009, the federal Department of Health and Human Services (HHS) issued the interim final rule regarding notification of breaches of unsecured protected health information under the privacy and security provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (more…)
Category: HIPAA |
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Adam V. Russo | August 28, 2009
from Spencer’s Benefits Reports: For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform. (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 28, 2009
Reprinted from REPORT ON PATIENT PRIVACY, the industry’s most practical source of news on HIPAA patient privacy provisions.
The first batch of government reviews of covered entities (CEs) for compliance with the security rule revealed a host of deficiencies, ranging from failure to conduct even an initial risk assessment to inconsistent employee training, according to a summary of findings and recommended corrective actions recently released by CMS. (more…)
Category: HIPAA |
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Adam V. Russo | August 28, 2009
by Guest Authors / by David Lemire(David Lemire worked for over 30 years as an underwriter at a large, multi-state HMO.)
Now that President Obama has changed his rhetoric from reforming health “care” to reforming health “insurance,” you any be asking yourself what insurance reforms are needed. (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 28, 2009
This is another in a series of regular health care reform updates from Spencer’s Benefits Reports. Included are links to items already covered, brief summaries of actions taken by the federal government, recent reports and studies on health care reform, policy statements by major stakeholders, and other recent health care reform activity. (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 24, 2009
by Timothy P. Carney, The Examiner, www.sfexaminer.com
Did you know that if your job-based HMO wrongly denies you coverage for a medical treatment and that denial leads to injury or death, federal law may protect that insurer from paying any damages to you or your family? (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 24, 2009
by David B. Rivkin Jr. and Lee A. Casey, The Washington Post, www.washingtonpost.com
President Obama has called for a serious and reasoned debate about his plans to overhaul the health-care system. Any such debate must include the question of whether it is constitutional for the federal government to adopt and implement the president’s proposals. Consider one element known as the “individual mandate,” which would require every American to have health insurance, if not through an employer then by individual purchase. This requirement would particularly affect young adults, who often choose to save the expense and go without coverage. Without the young to subsidize the old, a comprehensive national health system will not work. But can Congress require every American to buy health insurance?
(more…)
Category: Health Care Legislation |
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Adam V. Russo | August 19, 2009
by Paul Raeburn, www.kaiserhealthnews.org
On the evening of March 1, 2008, Gary Diego was relaxing with his wife, Ellen, when she abruptly lost her hearing, began repeating herself, and seemed to be losing her grip. (more…)
Category: Claims Procedures, Claims Review, Provider Reimbursement |
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Adam V. Russo | August 19, 2009
SIIA, www.siia.org
Media see softening administration position: Signs that a government-controlled health plan may not be part of national healthcare reform were reported early this week by many news media. The Wall Street Journal on Monday said, “The Obama Administration gave its strongest signal yet that it would be willing to compromise on plans to expand the government’s direct role in health-insurance coverage as it a fights growing crescendo of opposition to its effort to overhaul health care.” (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 19, 2009
The number of cases that apply the Supreme Court’s opinion in Metropolitan Life Insurance Company v. Glenn, 128 S. Ct. 2343 (2008) , when reviewing a decision to deny employee benefits by an administrator with a conflict of interest, continue to grow. The most recent example is Raybourne v. Cigna Life Insurance Company of New York, No. 08-2754 (7th Cir. 2009), where the plaintiff was a participant in his employer’s long-term disability benefits plan. (more…)
Category: 7th, Conflict of Interest, ERISA, MetLife v. Glenn |
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