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 25, 2012
The Eleventh Circuit Court of Appeals recently held in a case of first impression in this circuit that the Family and Medical Leave Act (FMLA) “protects a pre-eligibility request for post-eligibility leave.” That is, the FMLA protects an employee who gives notice, before she is eligible for leave, of intent to take FMLA leave for a qualifying reason once she becomes eligible. Pereda v. Brookdale Senior Living Communities, Inc., D.C. Docket No. 0:10-cv-60773-FAM, Eleventh Circuit Court of Appeals (January 10, 2012).
Category: 11th, FMLA |
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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
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 13, 2012
Top brass may have the last word when it comes to adverse actions. But even comments made by lower-level managers — including those in human resources — may be used to support the kind of discrimination claim that often follows in the highly emotional climate following a layoff.
A recent appeals court ruling in a Family and Medical Leave Act (FMLA) case illustrates the consequences for a company when HR doesn’t fully support the decision.
Category: 7th, FMLA |
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cmonfils | January 10, 2012
In order to support a valid claim of retaliation under the Family and Medical Leave Act (FMLA), an employee must demonstrate that the reason given for an adverse employment action was pretextual, and that the employee’s request for or use of FMLA leave was the actual basis of the action. The 6th U.S. Circuit Court of Appeals has held that an employer’s rejection of an invalid FMLA certification was a valid reason for termination, and that the employee’s inability to proffer evidence of an alternate explanation for the company’s actions led to the dismissal of her lawsuit. Coffman v. Ford Motor Company, 6th Cir., No. 10-3842, unpublished opinion, 11/22/11.
Category: 6th, FMLA |
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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 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 U.S. Supreme Court definitively announced on Nov. 14 it will decide the question of whether Congress exceeded its powers to regulate commerce when it decided to require people to buy health insurance (that is, whether the individual mandate is allowed under the U.S. Constitution). The court will hear National Federation of Independent Business v. Sebelius; and Florida v. HHS. The High Court will hear oral arguments in February and March 2012; it said it will issue a ruling in June 2012. It will also cover the question of “severability;” that is, the issue of whether the entire law must fall in the event that the individual mandate is stricken. The National Federation of Independent Business expressed hope that the Court would overturn the law, saying that it was putting a damper on business growth and job creation. (more…)
Category: 11th, 4th, Health Care Legislation, HHS, PPACA, Supreme Court, Washington D.C. |
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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 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 13, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 12/9/2011, www.Thompson.com
Case: US Airways, Inc. v. McCutchen, 2011 WL 5557411 (3rd Cir., Nov. 16, 2011)
Editor’s Note: In the11/28/2011 of this Newsletter, we published a review of this case by Agnes Mendoza-Ben-Yosef, BNA Pension & Benefits Daily Article via The Gibson Firm, LLC. We are now providing another view by Mr. Leeuwenburgh. (more…)
Category: 3rd, Reimbursement |
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cmonfils | December 12, 2011
Apparently, inspired by the recent Supreme Court decision in CIGNA v. Amara, the Third Circuit has held that the “appropriate equitable relief” qualifier in the grant of civil remedies under ERISA’s Section 501(a)(3) allows for the application of equitable defenses to plan reimbursement claims in – shall we say – “appropriate” situations. (I reviewed the lower court’s opinion previously.)
Category: 3rd, Subrogation |
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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.
Category: 5th, ERISA |
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