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 | May 9, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 5/4/2011, www.thompson.com
Case: Hansen v. Harper Excavating, 2011 WL 1379821 (10th Cir., April 13, 2011)
Fine distinctions about an employee’s status as a non-ERISA beneficiary allowed his state-law case — even though he had already prevailed on an ERISA complaint based on closely related facts — to survive, a U.S. appeals court has ruled in the above case. (more…)
Category: 10th, ERISA, Preemption |
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cmonfils | April 25, 2011
www.erisalawyerblog.com
By Stanley D. Baum on April 21, 2011
In Hansen v. Harper Excavating, Inc., No. 08-4089 (10th Cir. 2011), the plaintiff, Jeffery Hansen (“Hansen”), had worked for the defendant, Harper Excavating, Inc. (“Harper”), for six months beginning in 2003. During this time, he attempted to enroll in Harper’s health insurance plan (the “Plan”). The Plan is subject to ERISA. However, unknown to Hansen, Harper never enrolled him in the Plan, although it did deduct Plan contributions from his paycheck. (more…)
Category: 10th, ERISA |
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Adam V. Russo | September 7, 2010
MyHealthGuide, www.myhealthguide.com
By Tom Croft, Esq. of King & Croft LLP, www.StopLossLaw.com
Nationwide Life Ins. Co. v. City of Canton, Ohio, et al., No. 09AP-939, CPC No. 07CVH-08-11779 in The Court of Appeals of Ohio, Tenth District, 8/31/2010). Court’s Opinion
Mr. Croft’s comment: The myth that a stop loss carrier cannot win a disclosure dispute in court implodes yet again. This case involved a classic disclosure-issue fact pattern concerning a participant’s esophageal cancer, and a failure to make required disclosure on the part of the insured and one of its two TPAs. Relatively large dollars were involved. The Court of Appeals determined that the trial court had been correct in entering judgment for the stop loss carrier and its MGU. (more…)
Category: 10th, Ohio, Stop Loss, Welfare Benefit Plans |
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Adam V. Russo | December 21, 2009
– On December 9, 2009, the United States Court of Appeals, Tenth Circuit, affirmed the federal government’s position that private insurance companies are “plans” and therefore subject to federal jurisdiction. (US vs. Frost)
Although other federal courts have held that contracts issued by insurance companies may be subject to federal jurisdiction under Title 18 Section 1347, US vs. Frost is the first case an insurance company itself has been held to be a “plan,” because, as the government claimed in this case, all insurance companies are “plans.” (more…)
Category: 10th, ERISA |
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Adam V. Russo | October 12, 2009
by Joe Hanel of The Durango Herald, www.durangoherald.com
DENVER – Stephen and Naomi Dobbs have some of the same complaints about stonewalling by their health-insurance company as many people.
But when the Durango couple sued Anthem Blue Cross & Blue Shield, they got caught between two complex areas of the law – health insurance and Native American tribal sovereignty. (more…)
Category: 10th, ERISA |
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Adam V. Russo | July 28, 2009
In Administrative Committee of the Wal-Mart Stores, Inc. v. Gamboa, 479 F.3d 538 (8th Cir. 2007), an ERISA plan administrator brought suit seeking equitable reimbursement from a plan participant who had received a settlement from a tortfeasor. Although the reimbursement provision was contained in an SPD for a health plan, the employer had no formal written health plan. Reversing summary judgment for the participant, the Eighth Circuit held that the plan administrator reasonably construed the SPD to be on the plan document for purposes of a group health plan in the absence of any formal plan and that the reimbursement provision in the SPD was therefore enforceable. (more…)
Category: 10th, 7th, 8th, Fiduciary Liability, Plan Language, Summary Plan Description |
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Adam V. Russo | July 18, 2007
The Tenth Circuit Court of Appeals held in Hollingshead v. Blue Cross Blue Shield of Oklahoma, 2007 WL 475832, 39 EBC (BNA) 2732 (10th Cir. 2007), that when a Plan states it will pay for only one organ transplant, the Plan may exclude charges incurred for the replacement of a previously transplanted organ that has failed. (more…)
Category: 10th, Summary Plan Description |
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