Adam V. Russo | August 27, 2010
Employer’s Guide to Self-Insuring Health Benefits, Thompson Publishing Group
Employers and other plan administrators are due greater deference in their benefits plan decisions than some lower courts have allowed, the U.S. Supreme Court ruled after admonishing two lower courts for failing to follow the High Court’s prior decisions establishing ERISA law on plan administration.
The High Court also admonished the current administration as well as courts for attempting to introduce more complex, inefficient and costly requirements in plan decision-making, and for encouraging court interference in those plan decisions. (more…)
Category: 2nd, ERISA, MetLife v. Glenn, PPACA, Summary Plan Description, Supreme Court |
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Adam V. Russo | August 27, 2010
Employer’s Guide to Self-Insuring Health Benefits, Thompson Publishing Group
Employers and other plan administrators are due greater deference in their benefits plan decisions than some lower courts have allowed, the U.S. Supreme Court ruled. The Court’s 5-3 opinion in Conkright v. Frommert allows ERISA plan administrators to retain deferential review even after an erroneous interpretation of the plan. The plan was acting in good faith, its miscalculations were honest, the errors were isolated and a “one-strike-you’re-out” approach was unreasonable, Chief Justice John Roberts stated in the majority opinion. Deference should be upheld where possible, because if not, litigation becomes more labyrinthine and frequent, and plan administration becomes more complicated, the Court concluded. However, he noted, patterns of wrong plan interpretations — even in good faith — are still grounds for forfeiting deference.
Category: ERISA, Supreme Court, Welfare Benefit Plans |
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Adam V. Russo | August 27, 2010
Study shows projected average increase up from 7% this year
By Jerry Geisel of Business Insurance Magazine, www.businessinsurance.com
After years in which annual group health care plan cost increases have held steady in the 6% to 7% range, large employers are expecting much bigger increases in 2011, according to a survey released last week.
Employers responding to a National Business Group on Health survey said they expect costs to shoot up by an average of 8.9% next year, up from a projected average increase of 7% this year. (more…)
Category: Health Care Legislation |
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Adam V. Russo | August 27, 2010
Business Insurance Magazine, www.businessinsurance.com
Employers that want to get the most out of their investments in employee benefit programs will want to consider how and where their dollars are being spent and the effect on worker health and productivity, according to a new white paper published by Business Insurance.
“Maximizing Health Care ROI: How to Get the Most Bang for Your Benefits Buck” advises employers how implementing plan designs that appeal to their specific employee populations will encourage them to be smarter health care consumers, seek out preventive care and adopt healthy lifestyles that ultimately will reduce overall health care spending. (more…)
Category: Welfare Benefit Plans |
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Adam V. Russo | August 27, 2010
By Jerry Geisel of Business Insurance Magazine, www.businessinsurance.com
WASHINGTON—The once politically popular program that provides COBRA premium subsidies for involuntarily terminated employees is winding down as broad congressional support has nearly vanished, experts say.
Embedded in a 2009 economic stimulus measure and renewed several times since then, the program in which the federal government pays 65% of the COBRA premium has enabled millions of employees who lost their jobs and their dependents to keep group coverage by making it more affordable. (more…)
Category: COBRA |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
The government has yet to sort out the conflicting interests involved in subrogation/reimbursement dispute. Because there will be no reform body directly creating subrogation/reimbursement rules, the matter remains one of balancing various laws. For instance, laws in many states limit plans’ ability to recover health expenses based on the “make-whole,” “collateral source” and “common fund” rules. States have an interest in: (1) keeping the cost of auto liability insurance low; (2) ensuring that wrongdoers pay full damages; and (3) making sure attorneys are paid for representing clients. These are at odds with the federal government’s goal of keeping the cost of health coverage reasonable. It remains to be seen if the federal government will try to resolve this through preemption of state laws beyond self-funded ERISA plans.
Category: Attorneys' Fees, ERISA, Made Whole Rule, Preemption, Subrogation |
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Adam V. Russo | August 25, 2010
By Jack B. Helitzer, Esq., Coordination of Benefits Handbook
The federal health care reform law attempted to address two major problems with health coverage in the United States; (1) expansion of coverage to the uninsured; and (2) reducing overall health care costs. Most reform provisions won’t take effect for at least a few years. That’s because time is needed to develop regulations dealing with the vast scope and complexity of those problems, and because of the need to phase in increased costs that reform will cause in its early years. That means we really won’t know whether or not the law will achieve either goal, or even if it will survive the current complex political situation. (more…)
Category: ERISA, Health Care Legislation, Made Whole Rule, Preemption, Subrogation |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
Victims of accidents in subrogation/reimbursement cases have emotional appeal when they argue that tort settlements are reduced without some consideration of the fact that they were not “made whole” or had their recoveries diminished by not requiring a recovering plan to share the legal fees they incurred in making the settlement. There can be cases where the amount of the tort settlement seems to include significant amounts to reimburse losses beyond actual medical expenses incurred by the plan participant and paid by the ERISA plan. In this case, the 11th Circuit upheld an earlier ruling allowing the plan to recover the full amount it paid to a participant who received a much larger settlement. The decision was unusual in the clarity of its explanation of why the subrogation was in fact equitable. The plan gained an advantage by becoming involved in the tort settlement early enough to ensure a separate and identifiable portion of the settlement was set aside. (more…)
Category: 11th, ERISA, Made Whole Rule, Stop Loss, Subrogation, Summary Plan Description |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
Although federal case law is well settled on the principle that an ERISA health plan is entitled to reimbursement of benefits paid from tort settlement proceeds that are clearly identified as such, it appears that attorneys for plan participants still come up with several arguments seeking to avoid such liability. Those arguments often rely on state statutes, but they often raise other issues. A recent decision by a U.S. District Court in Georgia in favor of the plan’s right to reimbursement indicates how modern federal courts dispose of those arguments. The case is Brown & Williamson Tobacco Corp. v. Collier, 2010 WL 1487772 (M.D. Ga., April 13, 2010). (more…)
Category: ERISA, Georgia, Made Whole Rule, Subrogation, Summary Plan Description |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
As we have often seen in cases involving tort settlement proceeds arising from auto accidents, Michigan’s no-fault auto insurance law (Mich. Comp. Laws §500.3135) provides that Michigan drivers can buy secondary no-fault coverage at lower premiums. The law prevents insured health plans issued in Michigan from seeking reimbursement for medical expenses from tort settlement proceeds. (more…)
Category: ERISA, Michigan, Subrogation |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
We are familiar with cases where ERISA and state laws conflict. As we know, self-insured health plans that are subject to ERISA may avoid the application of state laws because of ERISA preemption. As we have seen in our analysis of the case Bash v. State Farm Mutual Automobile Insurance Co. on page 11 of this Newsletter, the objectives of ERISA sometimes conflict with the objectives of state laws. (more…)
Category: ERISA, New Jersey, Preemption, Subrogation, Supreme Court, Welfare Benefit Plans |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
The California Penal Law §202.4(f) requires that anyone who is found guilty of a criminal act that results in harm to a victim to provide restitution for economic losses incurred by the victim. A recent decision by a California Court of Appeal required such restitution based on the billed medical expenses incurred rather than on lower rates negotiated by that person’s medical insurer. The case is People v. Scott, 2010 WL 1820181 (Cal. App., 4 Dist., May 7, 2010). (more…)
Category: California, Subrogation |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
In a case that does not involve a health plan subject to ERISA, a Florida appellate court ruled that a health plan’s reimbursement from the proceeds of a settlement of a medical malpractice case was limited to the amount paid by the plan less its pro-rata share of attorney’s fees incurred by the plaintiff. The case is Ingenix v. Ham, 2010 WL 1780012 (Fla. App., May 5, 2010). (more…)
Category: Attorneys' Fees, ERISA, Florida, Preemption, Subrogation |
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Adam V. Russo | August 25, 2010
Coordination of Benefits
The common-law collateral source rule is intended to ensure that a person who suffers a financial loss as a result of other person’s wrongdoing does not achieve reimbursement of more than 100 percent of the loss from all sources. In Ohio, the modern collateral source rule is governed by a statute that permits the alleged wrongdoer to “introduce evidence of any amount payable as a benefit to the [injured party] as a result of the damages that result from an injury, death or loss to person or property that is the subject of a claim upon which the action is based, except of the source of collateral benefits has… a contractual right of subrogation.” The Supreme Court of Ohio recently considered the application of the statute in determining how much the injured party received in benefits from his health insurer. The case is Jacques v. Manton, 2010 WL 1816324 (S. Ct. Ohio, May 4, 2010). (more…)
Category: Ohio, Subrogation |
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Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
Medicare clearly has a right of reimbursement of payments it made for medical services when a third party is determined to have responsibility for those expenses. 42 U.S.C. 1395y(b)(2). New Jersey’s collateral source rule provides that if a person receives benefits for injuries from any source other than a joint tortfeasor, those benefits shall be disclosed to the court and the amount that duplicates any benefit contained in the award shall be deducted from any award recovered by that person. (N.J.S.A. 2A:15-97). A recent decision of the Appellate Division of the Superior Court of New Jersey considered how those two statutes interact. The case is Jackson v. Hudson Court, LLC, 2010 WL 2090036 (N.J. Super, App. Div., May 24, 2010). (more…)
Category: Medicare, New Jersey |
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