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 intentional self-inflicted injury” or “use of…intoxicants.” According to the death certificate, corroborated by police reports, the insured died after he “drank antifreeze,” which the coroner called an “accident.” The court criticized Aetna for failing to construe what the decedent’s intent was when he drank antifreeze and concluded Aetna should have sought “to clarify the ambiguous record prior to making a decision on the intertwined questions of whether [the insured] died” of accidental causes.
Category: Claims Procedures, Exclusion, South Carolina |
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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 of Labor, which tells HCSC which federal employees have what coverage, instructed HCSC that Pollitt’s coverage was for herself only rather than for herself and her family. According to Pollitt’s complaint in this suit, however, HCSC reached this conclusion on its own because the Department of Labor had failed to pay the appropriate premium into a fund that covers the expense of the medical benefits. Instead of checking with the department or with her, Pollitt’s complaint alleged, HCSC abruptly stopped covering Michael’s medical expenses and made demands for reimbursement that subjected her family to humiliation and expense. Just as abruptly, HCSC changed course in October 2007 and started paying the claims again. But even then, Pollitt asserted, HCSC did not inform medical providers, who continued trying to collect from Pollitt the back payments they thought HCDC was dunning them for. (more…)
Category: 7th, Claims Procedures, Claims Review, Exclusion |
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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 and pays the benefits under the policy. In McCauley, the Second Circuit abandoned its prior standard of review, which allowed courts to review de novo the administrator’s decision when it is shown that a conflict of interest actually influenced that decision, and adopted the Glenn standard that such a conflict of interest is to be “weighed as a factor in determining whether there was an abuse of discretion.” (more…)
Category: 2nd, Claims Procedures, Claims Review, Conflict of Interest, MetLife v. Glenn |
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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 some of the rules. But, the game is not necessarily over and there is no reason to forfeit. (more…)
Category: Bankruptcy, Claims Procedures, Subrogation |
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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 under § 510 of the Employee Retirement Income Security Act (ERISA). The court said Pailleret had no “smoking gun” evidence of intent, but the fact that almost immediately after he submitted medical claims of tens of thousands of dollars, he was assigned low-level and “degrading” tasks and shortly after that was terminated without notice or explanation was sufficient to show a plausible claim and “to thus unlock the doors of discovery.” (more…)
Category: 3rd, Claims Procedures, Conflict of Interest, Federal Circuits, New Jersey |
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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 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 self-insured employers to doctors and other health-care providers.
Under pressure from doctors, Metro Nashville Public Schools and Cookeville (TN)-based trucking company, Averitt Express Inc. asked Health Research Insights to stop sending letters that physicians say assume wrongdoing on their part without a review of related medical records. (more…)
Category: Claims Procedures, Claims Review, ERISA, News, Provider Reimbursement, Third Party Administrators |
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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. (more…)
Category: Claims Procedures |
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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 the provider, the patient and the insurer. The provider just wants to be paid its standard charge, the patient wants the insurer to cover whatever the patient owes, and the insurer wants to limit its outlay to the payment of a reasonable charge. (more…)
Category: Claims Procedures, Provider Reimbursement |
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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 accused of breaching its duties under ERISA, the stakes are high. ERISA Section 409 imposes personal liability on a fiduciary that breaches its duty. ERISA authorizes lawsuits against fiduciaries by participants, beneficiaries, the plan administrator, other fiduciaries ,and the U.S. Department of Labor. The federal courts have uniformly held that ERISA’s fiduciary duty is “the highest duty known to the law.” (more…)
Category: Claims Procedures, Claims Review, ERISA |
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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 the merits of their allegations.
Few plaintiffs are able to meet these burdens, and so either don’t sue or often get their lawsuits quickly dismissed. Until recently most courts were not very sympathetic to plaintiffs’ arguments of procedural violations, but things are changing, the most significant development being the Supreme Court’s decision this summer in MetLife v. Glenn. (more…)
Category: 7th, 9th, Claims Procedures, Claims Review |
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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 or will settle, and thus for which the insured has removed liability from the third party and shifted responsibility onto him or herself.
Confusion regarding how a benefit plan and its administrator handle future claims resulting from an incident for which another party is or may become responsible is widespread. The greatest mistakes administrators make is confusing “offset” with “future credits” and other future claims, as well as confusing subrogation with exclusions. (more…)
Category: Claims Procedures, Claims Review, Offset |
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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 of interest if it not only determines whether a claim is payable, but also pays the claim with its own funds. (more…)
Category: 6th, Claims Procedures, Claims Review, Supreme Court |
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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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