bhoffman | August 25, 2010
SIIA, www.siia.org
Oklahoma Tax on Paid Claims Ruled Unconstitutional
This afternoon, a recently enacted tax that would have applied to all claims paid in Oklahoma by health plans, was struck down by the Oklahoma Supreme Court.
Earlier this summer, the Oklahoma State Legislature passed a measure, subsequently signed into law by the Governor, which would have assessed a [...]
bhoffman | August 5, 2010
Bryan Cave LLP, www.bryancave.com
The Departments of Treasury, Labor and Health & Human Services (the “Departments”) recently issued two more batches of interim final regulations under the Patient Protection and Affordable Care Act, as amended (the “Act”). This new guidance addresses (i) the preventive services coverage mandate, and (ii) the new internal claims and appeals and [...]
Adam V. Russo | July 9, 2010
In the context of an ERISA claim in which the insurer’s structural conflict of interest was a factor in the court’s analysis, the court concluded the record was insufficient to determine if the insured’s drinking antifreeze was accidental in Catledge v. Aetna Life Insurance Co. The policy excluded loss “caused or contributed to by: an [...]
Adam V. Russo | July 9, 2010
Juli Pollitt, a federal employee, had health insurance administered by Health Care Service Corp. (HCSC). In July 2007, HCSC stopped paying claims submitted on behalf of Pollitt’s son Michael and began trying to collect from health care providers any payments made on Michael’s behalf since 2003. According to HCSC, it did this because the Department [...]
Adam V. Russo | July 9, 2010
In light of the Supreme Court’s decision in Glenn, the Second Circuit has reassessed its standard of review governing cases that challenge an ERISA plan administrator’s decision to deny disability benefits in cases where the administrator has a conflict of interest because it has the discretionary authority to determine the validity of the employee’s claim [...]
Adam V. Russo | March 22, 2010
By Cameron D. Gray, Esq., Boteler, Mahoney & Gray, LLP, Dallas, Texas
The United States Bankruptcy Code is intended, at least in part, to give a debtor in bankruptcy relief from the demands of its creditors so that it can regroup and potentially survive those claims. It does this by shifting the playing field and changing [...]
Adam V. Russo | January 29, 2010
January 22, 2010 (PLANSPONSOR.com) – A federal court has refused to dismiss a claim by a Jersey Construction employee that he was fired for pursuing health benefits for his wife’s chemotherapy.
The U.S. District Court for the District of New Jersey said it found that Christian Pailleret stated sufficient facts to support a prima facie case [...]
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.
Adam V. Russo | August 5, 2009
Reaction from AMA, TMA, GMA, Self-Funded Employer• Getahn Ward, The Tennessean, 5/16/09, Tennessee HRI Article
• Emily Berry, American Medical News, 4/13/09, AMedNews Article
• Tennessee Medical Association (TMA) Legal Department 5/5/09, TMA Alert on HRI Recoupment Letters
Franklin (TN)-based Health Research Insights, has temporarily halted efforts to collect on potential overpayments of medical claims by two Nashville-area [...]
Adam V. Russo | May 29, 2009
by Kristin Gunderson Hunt of Business Insurance, www.businessinsurance.com
Approximately $19 billion designated for health care information technology in the economic stimulus package signed into law by President Obama and the push to establish an electronic medical record for every U.S. citizen by 2014 likely will not directly affect employers and their benefits departments, experts say.
Adam V. Russo | January 28, 2009
One of the biggest problem areas in the healthcare industry is the practice of balance billing of patients by non-participating providers for services reimbursed by the patient’s insurer at less than the provider’s billed charges. The providers’ demand to be paid the balance then becomes a point of contention in a three way battle between [...]
Adam V. Russo | November 6, 2008
Based on the Supreme Court’s decisions in MetLife and LaRue, employers should consider making changes and acting proactively to implement strategies to help ensure that plan disputes are channeled through a committee and that the committee’s decisions receive deference from the courts.
Many corporate officers, employees and board members serve as ERISA fiduciaries. For a fiduciary [...]
Adam V. Russo | November 6, 2008
TPAs rely heavily on ERISA’s requirements that claimants must exhaust their administrative remedies before going to court, and when they do sue, assuming that the Plan documents grant the claim administrator the appropriate discretionary authority, they must show that the claim administrator abused its discretion when denying their claim, before any court will get to [...]
Adam V. Russo | September 23, 2008
by Ron E. Peck, Esq.
Offset: Denying future claims to reimburse the Plan for claims it has paid prior to third party settlement. It is a form of lien reimbursement.
Denial of Future Medical Claims: Denying future claims because they were caused by, and are the responsibility of a third party with whom the insured has settled [...]
Adam V. Russo | February 20, 2008
The Supreme Court will be granting certiorari to MetLife, et al., v. Wanda Glenn. While MetLife v. Glenn reinforces a third party administrator’s (“TPA”) right to make administrative decisions and interpret the terms of benefit plans when it is not the party funding the plan, this case asks whether a Plan Administrator faces a conflict [...]
