cmonfils | December 12, 2011
The United States Court of Appeals for the Fifth Circuit, reversing a lower court decision, has ruled that ERISA does not preempt certain state statutory and common law claims for negligent misrepresentation and other unfair and deceptive practices.
cmonfils | December 5, 2011
MyHealthGuide Source: Thomas Croft, Esq., King & Croft LLP, 12/2/2011, www.StopLossLaw.com
Case: Hebrew Home of Greater Washington, Inc. v. CoreSource, Inc. and Sun Life Assurance Co. of Canada; No.11-cv-00710, in the United States District Court for the District of Maryland, 11/3/2011. Court’s Opinion
Mr. Croft’s Comment: A Maryland federal court has determined that a self-insured group’s claims against its TPA are only partially pre-empted by ERISA and that a payment outside a stop loss policy’s run-out period is ineffective to trigger coverage, despite a claim that the payment “substantially complied” with the policy’s terms. (more…)
cmonfils | November 30, 2011
The US Court of Appeals for the Third Circuit held that, under ERISA Section 502(a)(3), an employee benefit plan was not entitled to full reimbursement for medical expenses it incurred on behalf of a participant and was limited by equitable principles and defenses to “appropriate” relief, despite plan language specifying full reimbursement. In its decision in US Airways v. McCutchen, the court held that the plan could not recover the full cost of the participant’s medical expenses when the participant recovered less from a third party.
cmonfils | November 30, 2011
In a case of significant importance for plan sponsors and fiduciaries, the U.S. Court of Appeals for the Third Circuit held in US Airways, Inc. v. McCutchen, No. 10-3836 (3d Cir. Nov. 16, 2011), that an employee benefit plan was not entitled to full reimbursement of medical expenses it paid to a participant even though the plan provided that the participant was required to reimburse the plan for all amounts paid “out of any monies recovered from a third party.” The Court found that, because the participant had not received a complete recovery for his injuries in collateral litigation, full reimbursement to the plan would not be consistent with the terms of Section 502(a)(3) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132(a)(3), which limits recovery to “appropriate equitable relief.”
cmonfils | November 29, 2011
MyHealthGuide Source: Agnes Mendoza-Ben-Yosef, 11/17/2011, BNA Pension & Benefits Daily Article via The Gibson Firm, LLC
Case: US Airways Inc. v. McCutchen, 3d Cir., No. 10-3836, 11/16/11. Court’s Opinion
Article referred by John H. Eggertsen, Esq., Eggertsen Consulting, P.C.
US Airways Inc.’s health benefit plan is not entitled to full reimbursement from an insurance settlement for the medical costs it paid on behalf of a plan participant because the recovery would exhaust the participant’s entire settlement, the U.S. Court of Appeals for the Third Circuit ruled Nov. 16 in the above case. (more…)
cmonfils | November 29, 2011
THIRD CIRCUIT HOLDS THAT ERISA PLANS REIMBURSEMENT CLAIMS ARE SUBJECT TO EQUITABLE DEFENSES AND LIMITATIONS
On November 16, 2011, the Third Circuit held in US Airways, Inc. v. McCutchen, that an ERISA plan’s claims for reimbursement under ERISA §502(a)(3) are subject to equitable limitations and defenses. The matter involved a self-funded ERISA plan which had paid $66,866 on behalf of a plan participant who was injured in an automobile accident. (more…)
cmonfils | November 20, 2011
The Department of Labor has slightly delayed the deadlines on significant new affirmative obligations for fiduciaries of retirement plans subject to the Employee Retirement Income Security Act.
Although the deadlines have been pushed from this July to April 1, 2012, employers should be preparing now to ensure that they are ready to comply with the new requirements.
cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
A plan participant cannot pick definitions from various state or federal statutes and impose them on the plan where the plan left terms undefined, if the plan applies a common and ordinary meaning to those terms when asked to justify a claims denial.
Applying this rule, a Michigan appeals court affirmed a lower state court’s ruling upholding a plan’s benefits denial for a surrogate mother’s delivery of triplets. (Spectrum Health v. Lehr, No. 298688, (Mich. App., Sept. 8, 2011).) (more…)
cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
A plan’s decision to circumvent its own written appeals procedures led to ERISA claims. In a dispute involving an experimental service denial, plan administrator Viacom and claims administrator United Healthcare told a plan participant to skip the plan’s normal appeals route and appeal to Viacom, because it might overrule the plan’s exclusion or revise the plan to allow payment for the service. When the plan sponsor fumbled its decision, gave conflicting explanations and took months to ultimately deny the claim, the participant sued alleging unpaid benefits, breach of fiduciary duty and other charges. United managed to get all breach of fiduciary duty charges waived but the Viacom defendants still have to face all charges. Wrongful denial of benefits charges still stand against both defendants. (more…)
cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
The 9th U.S. Circuit Court of Appeals ordered Blue Shield of California, the plan administrator of an insured ERISA plan, to cover a residential stay for psychological treatment despite plan terms excluding residential stays of any kind. The court even found that Blue Shield gave its plan document a sound reading. California’s Mental Health Parity Act provides coverage for “medically necessary” diagnosis and treatment of “severe mental illnesses,” whether or not it involves a residential stay. The court rejected Blue Shield’s attempt to circumscribe the Parity Act to services listed in that Act and matching the Knox-Keene Act. Then the court held Blue Shield forfeited its right to argue against medical necessity in court because it had not done so in the administrative stage. (more…)
cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
The federal agencies in charge of implementing health reform and the National Association of Insurance Commissioners (NAIC) keep saying stop-loss policies with low attachment points mean an employer-sponsored health plan is really not self-funded. Contributing Editor Adam V. Russo and Attorney Ron Peck say that NAIC experts are trying to reduce the number of employers that choose self-funding because they: (1) want to force more healthy employees into state-run insurance exchanges; and (2) feel that if they can’t regulate ERISA plans, ipso facto, consumers are put in danger. In doing this they are ignoring a tidal wave of legal precedent holding that self-funded health plans remain that way regardless of the kind of stop-loss insurance the sponsor chooses. Eliminating the option to purchase stop-loss for smaller groups would raise health insurance costs for everybody, Russo and Peck say. (more…)
cmonfils | November 18, 2011
Employer’s Guide to Self-Insuring Health Benefits October 2011 | Vol. 19, No. 1
A federal appeals court lined up with two lower court rulings in deciding that a hospital and a physician practice were not liable under ERISA to return money to a plan that mistakenly paid claims for a plan member’s ineligible daughter.
The 7th U.S. Circuit Court of Appeals said because the child was never enrolled in the plan, the plan’s suit to enforce ERISA rights or duties could not work, in Kolbe & Kolbe Health and Welfare Ben. Plan v. Medical College of Wisconsin, Inc., 2011 WL 3873773 (7th Cir., Sept. 2, 2011). (more…)
cmonfils | November 16, 2011
In our prior blog, we explained that under principles of triage, employers may need to focus on the current annual enrollment and wait to take care of the Summary of Benefits and Coverage (“SBC”). Although the SBC does not need immediate attention, we caution employers not to wait too long or take the SBC responsibilities too lightly. The penalties for failing to satisfy the SBC requirements are severe. This blog will explain what those penalties are and the steps to take to avoid them. In a subsequent blog, we will provide more details regarding specific content requirements and the different groups of people who must be given the SBC.
cmonfils | November 14, 2011
MyHealthGuide Source: Kenneth A. Mason, Benefits in BriefSM Spencer Fane Britt & Browne LLP, 11/9/2011, www.spencerfane.com
Case: Bio-Medical Applications of Tennessee, Inc. v. Central States Southeast and Southwest Areas Health and Welfare Fund
Article referred by: John H. Eggertsen, Esq.
A federal appeals court has held that the Medicare Secondary Payer (“MSP”) Act authorizes a medical provider to sue an employer health plan for double damages when the plan fails to comply with the MSP Act, thereby forcing the provider to accept the lower level of reimbursement available under Medicare. This Sixth Circuit decision, in the above case, definitely raises the stakes for health plans that fail to comply with the MSP rules. (more…)
cmonfils | November 11, 2011
Washington, D.C. – The ERISA Industry Committee (ERIC) yesterday submitted two comment letters on proposed regulations under the Patient Protection and Affordable Care Act (ACA). The first letter addresses a proposed regulation to implement provisions relating to how the exchanges interact with employers to determine whether an individual is eligible to purchase subsidized health coverage through an exchange. The second letter addresses a proposed safe harbor for determining the affordability of employer-sponsored coverage for purposes of the shared-responsibility provisions of the ACA.
