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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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
In a lawsuit involving denied gastric repair services, a third-party administrator (TPA) argued its way out of an ERISA claim for denied benefits and alleging fiduciary abuse, after the court agreed it only did what the plan sponsor told it in documents, e-mails and conversations.
The plaintiff accused the TPA of being a de facto plan administrator, in spite of the fact the plan document expressly disavowed any fiduciary role for the TPA. (more…)
Category: 10th, ERISA, Fiduciary, Third Party Administrators |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The attempted treatment of stop-loss coverage as “health insurance” subject to state insurance law has been a thorn in the sides of self-funded plans seeking to maintain ERISA preemption of state insurance laws.
In Goyen v. Vail Corp., 2011 WL 4479091 (D. Colo., Sept. 26, 2011), a federal district court rejected a plaintiff’s argument that a plan stopped being self-funded and lost ERISA preemption, all because it had taken out a stop-loss policy. (more…)
Category: 3rd, 6th, ERISA, Preemption, Self-Funding, Stop Loss |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The recently proposed summary of benefits and coverage (SBC), while still a work in progress, will fill a currently unmet need for a tool enabling plan participants to comparison-shop for coverage, federal regulators told a recent conference. They sought to allay plan sponsors’ concerns that the SBC is redundant, confusing or even regressive. (more…)
Category: DOL, ERISA, Health Care Legislation, HHS, HIPAA |
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cmonfils | December 30, 2011
A lawsuit filed last week in Federal Court seeking a declaration that Michigan’s Health Insurance Claims Assessment Act is preempted by the Employee Retirement Income Security Act (ERISA) will certainly test existing legal precedent, but perhaps the more interesting test will be how the business community will respond.
I previously reported that officials from one prominent business organization in the state had no intention of pushing back against the legislation at the time citing both internal and external political concerns. That said, they suggested that there would likely be “private” support of a legal challenge from within their organization if in fact the law was challenged.
http://self-insuranceworld.blogspot.com/
Category: ERISA, Health Insurance, Michigan |
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cmonfils | December 29, 2011
In Mitchell, et. al. v. Marcus Tyrone Robinson, Sr., et. al. the Plaintiffs are the grandparents of some minor children of Marcus Tyrone Robinson and his deceased wife. The allegation is that Mr. Robinson killed his wife. The wife had $121,000.00 in life insurance through her employer, Unilever, and insurer MetLife. Mr. Robinson made a claim for benefits under the policy which was paid. Thereafter, the grandparents filed suit alleging that Mr. Robinson was not entitled to recover under the Missouri Slayer Statute, and claimed that the benefits were wrongfully paid as a result thereof. Plaintiffs asserted several state law claims to recover the money and named Unilever and MetLife as Defendants. In the attached order the court is deciding Unilever’s motion to dismiss the state law claims based upon ERISA preemption. The court holds that the Missouri Slayer Statute is preempted.
Category: ERISA, Missouri |
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cmonfils | December 27, 2011
On November 16, 2011, a panel of the Third Circuit Court of Appeals decided US Airways v. McCutchen, No. 10-3836, 2011 U.S. App. LEXIS 22883 (3d Cir. Nov. 16, 2011). The Court claims to respond to the Sereboff court’s argument left open by footnote two in the Supreme Court’s decision in Sereboff v. Mid-Atlantic, which the Court declined to address because it was not raised in the district court or the Fourth Circuit: “…even if the relief Mid Atlantic sought was ‘equitable’ under § 502(a)(3), it was not ‘appropriate’ under that provision in that it contravened principles like the make-whole doctrine.”
Category: 3rd, ERISA, Subrogation |
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cmonfils | December 27, 2011
www.myhealthguide.com
MyHealthGuide Source: Joanne Wojcik, 12/22/2011, Business Insurance SIIA Article
DETROIT — The Self-Insurance Institute of America Inc. has filed a lawsuit challenging a new Michigan law that is to start assessing a 1% tax on paid health care claims after Jan. 1, 2012.
The tax, which is being used to help fund the state’s Medicaid program, would be paid by insurers offering fully insured plans and by third-party claims administrators and stop-loss insurers in the case of self-funded plans. The assessment would be paid quarterly starting April 15, 2012. (more…)
Category: ERISA, Medicaid, Michigan, Self-Funding |
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cmonfils | December 22, 2011
Beginning in 2011, health insurance issuers are required to spend at least 80 or 85 percent of their premiums on health care and health quality improvement activities, or provide rebates to the policyholders for the failure to do so. The first round of rebates, based on insurer financial data for 2011, is due by August 1, 2012. The Department of Labor issued guidance on how the rebates should be handled by ERISA group health plans.
Technical Release 2011-04 provides very specific parameters on how the rebates should be analyzed and handled by ERISA-covered group health plans and their sponsors. The advice includes:
Category: DOL, ERISA |
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cmonfils | December 22, 2011
December 22, 2011 — The Self-Insurance Institute of America, Inc. (SIIA) today announced that it has filed a complaint in Federal Court requesting a declaration that Michigan’s recently passed Health Insurance Claims Assessment Act is preempted by the Employee Retirement Income Security Act (ERISA). SIIA also seeks an injunction against implementation and enforcement of the Act involving self-insured group health plans that are subject to ERISA or their business partners. (more…)
Category: ERISA, Michigan, Third Party Administrators |
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cmonfils | December 21, 2011
Self-Insurer December 2011 Issue, Volume 38
By Michael Friedman and John Eggertsen
The subtleties of subrogation Analysis, or when drafting plan Language it is not so simple to say what you mean in a way a court will understand it.
For those who stick with this discussion of the Court’s assessment of the subrogation and reimbursement provisions in Two ERISA Plans, it will become abundantly clear that courts will review such provisions with the proverbial fine tooth comb, and that careful and explicit drafting is required in order for a plan administrator to enforce a plan’s rights. (more…)
Category: 9th, ERISA, HIPAA, Reimbursement, Subrogation |
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cmonfils | December 21, 2011
www.siia.org
December 15, 2011 – The Self-Insurance Institute of America, Inc. (SIIA) today filed an “initial” amicus brief with the Texas State Supreme Court in the case of GPA Holdings, Inc. v. Baylor Health Care Systems. This initial brief supports GPA’s request that the Supreme Court consider arguments to reverse an adverse judgment issued by the Fifth District Court of Appeals. Should the Court agree to hear arguments, SIIA will file a secondary, more comprehensive brief. (more…)
Category: ERISA, News, Self-Funding, Third Party Administrators |
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cmonfils | December 14, 2011
Background
Five years ago, in the Pension Protection Act of 2006, Congress provided that Tribal [Church] employee benefit plans would not be treated as “governmental” [church] unless all the participants are individuals “substantially all of whose services … are in the performance of essential governmental [church] functions but not in the performance of commercial activities (whether or not an essential government [church] function).” This requires Tribal [Church] employee benefit plans covering any ”commercial” employees to fully comply with the requirements of the Employee Retirement Income Security Act of 1974 (ERISA) and the Internal Revenue Code of 1986 (IRC) in the same manner as private sector business employer plans.
Category: ERISA |
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cmonfils | December 14, 2011
A significant conflict among the circuits exists as to whether extrinsic evidence (evidence that was not part of the administrative record) can be admitted into evidence when a claim denial for ERISA-regulated employee benefits is reviewed under the de novo standard. In some circuits, extrinsic evidence is usually allowed, in others sometimes allowed, and in still others, never allowed.
Category: ERISA, Health Insurance |
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