Adam V. Russo | July 9, 2010
In Kehoe v. 1st Source Bank Healthcare Benefits Plan,190 the court affirmed an ERISA plan administrator’s denial of health coverage where claimant had a blood alcohol level of 0.128, as tested at the treating hospital, and the plan excluded “[c]harges resulting from an illness or injury incurred while under the influence of alcohol or illegal [...]
Adam V. Russo | July 9, 2010
This year, while the Sixth Circuit held that an illegal act exclusion could not be applied because of a lack of causation between the illegal act and the injuries for which benefits were sought, an Indiana district court found that an administrator’s decision to deny health benefits based on a plan exclusion was “not reasonable” [...]
Adam V. Russo | July 9, 2010
In considering the administrative record in ERISA benefits cases, courts this year addressed both what must be included in the administrative record and the admissibility of its contents. In Nally v. Life Insurance Co. of North America, plaintiff argued her deceased husband’s employee benefit plan impermissibly relied on evidence such as police and expert reports [...]
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
The court in Munger v. Transguard Insurance Co. of America, Inc. distinguished between a foreseeable event and a foreseeable injury in upholding a denial of an accident claim. The plaintiff, a tractor and trailer operator, sustained injury to his back while performing the duties of his employment, which he had done “hundreds of times” over [...]
Adam V. Russo | July 9, 2010
This year’s lone felony/intoxication case raises an interesting question: when is driving under the influence a felony? In Kay-Woods v. Minnesota Life Insurance Co.,13 the insured died in a single-vehicle accident while driving with a revoked license and under the influence of alcohol and cocaine. The policy provided that benefits would not be paid if [...]
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 | November 23, 2009
By TIM HULL
(CN) – An insurance company must award benefits to an Ohio man who lost his leg in a drunken motorcycle crash, the 6th Circuit ruled, because the incident falls within the broad definition of an “accident.”
Adam V. Russo | October 28, 2009
Reporting to Medicare
The purpose of these reporting requirements is to enable the Centers for Medicare & Medicaid Services (CMS) to determine whether those covered by Medicare are also covered by other insurance that, by law, must pay primary to Medicare.
Adam V. Russo | September 29, 2009
by David S. Hilzenrath of The Washington Post, www.washingtonpost.com
A proposal to make preexisting health conditions irrelevant in the sale of insurance policies could help not just the seriously ill, but also people who might consider themselves healthy, documents released Friday by a California-based advocacy group illustrate.
Adam V. Russo | September 18, 2009
by Roy Harmon, III, www.healthplanlaw.com
A typical plan will contain an exclusion for accidents or injuries resulting from intoxication, unlawful conduct and so forth. How the plan states the exclusion can vary quite a bit, and the distinctions can make a significant difference in outcomes.
Adam V. Russo | July 28, 2009
In MacLeod v. Proctor & Gamble Disability Benefit Plan, 460 F. Supp. 2d 340 (D. Conn. 2006) the administrator denied the participant’s application for benefits on the grounds that the claimed disability resulted from the participant’s prior military service and therefore was excluded from coverage. At oral argument, the administrator admitted that its decision was [...]
Adam V. Russo | July 28, 2009
In Thomas v. Reliance Standard Life Insurance Co., 487. F. Supp. 2d 697 (D.S.C. 2007), the court examined whether death by asphyxia from vomitus resulting from drug self-administration was an accident within the terms of an ERISA-governed policy. Reliance Standard denied benefits pursuant to the policy’s exception for losses caused by suicide or intentionally self-inflicted [...]
Adam V. Russo | July 28, 2009
In Bond v. Ecolab, Inc., 2007 WL 551595 (E.D. Mich. Feb. 21, 2007, an ERISA plan participant died while engaging in autoerotic asphyxiation. The police and medical examiners concluded that the participant’s death was accidental. The plan’s claims administrator, MetLife, denied the beneficiary’s claim for benefits based on the plan’s exclusion for self-inflicted injuries. In [...]
Adam V. Russo | July 28, 2009
In Eckelberry v. Reliastar Life Insurance Co., 469 F.3d 340, the Fourth Circuit affirmed the insurer’s determination that the decedent’s fatal automobile collision did not qualify as an “accident” as defined under the subject ERISA plan. The insured died after he lost control of his car and collided headlong into the rear of a tractor [...]
