cmonfils | January 31, 2012
Coordination Of Benefits January 2012 Vol. 20 No. 1
In a surprising decision, the 3rd U.S. Circuit Court of Appeals used the concept of “appropriate equitable relief” to restrict an employer sponsored health plan’s recovery from a third-party settlement to less than what the plan paid out in health benefits. In US Airways, Inc. v. McCutchen, the appeals court held that full reimbursement of expenses to the employer-sponsored health plan would be “inappropriate and inequitable relief.” Full recovery would constitute unjust enrichment for the plan because: (1) the plan participant’s recovery ended being less than what the plan paid after attorney’s fees were deducted; and (2) the plan never intervened in the third-party recovery. The appeals court held these facts overruled the fact that the plan had subrogation reimbursement provisions asserting recovery rights over any monies collected from a third party, and it overturned a lower court’s decision requiring the participant to pay the plan the whole amount. (more…)
Category: 3rd, ERISA, Self-Funding, Supreme Court |
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cmonfils | January 31, 2012
Whether Leeson is a participant for purposes of ERISA is a substantive element of his claim, not a prerequisite for subject matter jurisdiction. As the Supreme Court has instructed, “when Congress does not rank a statutory limitation on coverage as jurisdictional, courts should treat the restriction as nonjurisdictional in character.” Arbaugh v. Y & H Corp., 546 U.S. 500, 516, 126 S. Ct. 1235, 163 L. Ed. 2d 1097 (2006).
http://www.healthplanlaw.com/?p=2220
Category: ERISA |
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cmonfils | January 25, 2012
Insurance coverage can be a confusing thing. Coverage for employee benefit plan fiduciaries sometimes adds a wrinkle to the process that can be overlooked. Depending on the type of claim asserted, there are a variety of “coverage” options that may apply. I think the new fee disclosure rules are likely to increase claims for breach of fiduciary duty in the future, but even without that development, it makes sense to at least know whether you have coverage and what your options are. So let’s take a look at some of the options.
Category: ERISA, Fiduciary |
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cmonfils | January 23, 2012
www.myhealthguide.com
MyHealthGuide Source:
What is the most comprehensive, intensive and proven consumer protection law in the nation? What law imposes such intense fiduciary duty that customs most businesses are free to use to increase their profits can land a fiduciary in jail? (more…)
Category: ERISA, Health Care Legislation, Health Insurance, Self-Funding |
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cmonfils | January 23, 2012
Many people assume insurance offered by their employer is a better deal than they can get on their own. But while the premiums can be lower, such policies have drawbacks.
Employer-sponsored insurance has become much more common in recent years. Premiums from new sales of life, disability, supplemental-medical and other types of insurance sold through work sites totaled an estimated $5.4 billion in 2011, up from $2 billion in 1997, according to benefits-expert Eastbridge Consulting Group.
http://online.wsj.com/article/SB10001424052970204331304577141080671882766.html
Category: ERISA, Health Insurance, Self-Funding |
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cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
As illustrated here, ERISA did not preempt the Washington Mental Health Parity Act.
Even though it correctly applied an insured ERISA plan’s coverage restrictions on neurodevelopmental therapy for children over six years old, the administrator’s refusal to pay a 10-year-old dependent’s mental health treatment violated a state law that bound insurers and HMOs. (more…)
Category: ERISA, Health Care Legislation, Mental Health Parity, PPACA, Preemption, Supreme Court, Washington |
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cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
A claims administrator lost an attempt to dismiss negligence and breach of contract charges relating to its failure to process and pay a large claim before the final day of a stop-loss policy’s run-out period.
The self-insured Hebrew Home health plan sued administrator CoreSource and stop-loss insurer Sun Life for negligence and breach of contract under state law, alleging that the administrator dragged its feet paying the claim and ended up missing a March 31 deadline that would have enabled the plan to collect $180,000 in stop-loss reimbursement. (more…)
Category: 4th, ERISA, Maryland, Preemption, Stop Loss |
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cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
Most self-insured governmental plans adopt ERISA principles in governing trusts, and use ERISA-style plan documents and summary plan descriptions (SPDs). However, just because they look to ERISA for guidance when crafting programs, they would be mistaken to assume they have ERISA-style rights.
In Daugherty v. Wayne County Bd., 2011 WL 5028365 (Ohio App. 9 Dist., Oct. 24, 2011), a self-insured county health plan argued that because it reserved itself discretionary authority in the SPD, that its disputed denials should be entitled to a more favorable review in court. (more…)
Category: ERISA, Ohio, Self-Funding, Summary Plan Description |
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cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
In a surprising decision, the 3rd U.S. Circuit Court of Appeals used the concept of “appropriate equitable relief” to restrict an employer-sponsored health plan’s recovery from a third-party settlement. Full reimbursement of what the plan paid out would have been “inappropriate and inequitable,” even though the plan had asserted recovery rights over any monies collected from a third party. Full recovery would have been unfair because: (1) the plan participant’s recovery ended up being less than what the plan paid after attorney’s fees were deducted; and (2) the plan never intervened in the third-party recovery. The outcome diverges from many recent cases, which upheld plans’ claims on total proceeds, regardless of whether the plan participant was “made whole” or had money to pay attorney’s fees. (more…)
Category: 3rd, Common Fund, ERISA, Pennsylvania, Reimbursement, Subrogation, Third Party Agreements |
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cmonfils | January 17, 2012
With little fanfare and little attention from the media, the Obama Administration recently issued proposed rules to crackdown on health insurance scams that use ERISA to avoid state law enforcement and regulatory actions.
Since the 1974 enactment of ERISA — the federal law governing employee pension and health benefit plans — crooks have used it to promote health insurance scams. There have been bipartisan Congressional attempts to address this problem, e.g., the passage of the 1982 amendments to clarify state authority and the 1996 HIPAA amendments to increase penalties for health fraud. But until the passage of the Patient Protection and Affordable Care Act (ACA), the federal government has had limited administrative authority to fight health insurance scams.
Category: DOL, ERISA, Health Care Legislation, Health Insurance, PPACA |
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cmonfils | January 12, 2012
Published by the Self-Insurance Educational Foundation, Inc. in cooperation with the Self-Insurance Institute of America, Inc.
Manage your Health Plan as you would manage your business. An introduction to self-funding.
“Become part of the Health Care solution!”
If there were a proven method to managing your health plan costs that over 57% of employees in the U.S. were utilizing today, would you be interested? Well there is a proven method, and it is called self-funding. (more…)
Category: ERISA, Plan Sponsor, PPACA, Self-Funding |
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cmonfils | January 8, 2012
www.myhea;thguide.com
MyHealthGuide Source: Scott Cooper, Attorney, SchmidtKramer Injury Lawyers1/6/2012, Injury BlogNetwork Blog Entry
Case: Bieber v. Nace, 2011 WL 6180719 (M.D.Pa. 12/13/2011). Court Ruling
The federal court for the Middle District of Pennsylvania in Harrisburg recently addressed an issue regarding the recovery of special damages in a MMotion in Limine (request of ruling) in the above case. The Plaintiffs filed a suit arising out of a car accident and their resultant injuries. (more…)
Category: 3rd, ERISA, Self-Funding |
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cmonfils | January 8, 2012
Many plan sponsors have not paid much attention to the U.S. Department of Labor’s current effort to substantially broaden the definition of a plan fiduciary, agrees Lynn Dudley, Senior Vice President, Policy, at the Washington-based American Benefits Council. They do it at their peril, she suggests. “Because there are so many lawsuits based on investment menus and investment choices, this is not something to take lightly,” she says.
Category: DOL, ERISA, Fiduciary |
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cmonfils | January 8, 2012
The District Court of Montana dismissed a putative class action against insurer John Alden last Thursday citing the Policy’s 3-year statute of limitations. The plaintiff brought suit against the insurer alleging it had used a defective database that produced inaccurate calculations for reimbursement of health care charges. Plaintiff was insured under an ERISA-governed employee welfare benefit plan that included medical coverage.
Category: ERISA, Reimbursement |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
A federal district court upheld a claim administrator’s denial of payment for stays at a hospital and a skilled nursing facility (SNF) for a plan participant on life support deemed not medically necessary under plan terms because his condition was past the point of improving. Most of the care he got at the facilities could have been provided in a less intensive setting. (more…)
Category: ERISA |
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