Archive for the ‘3rd’ Category

January 22, 2010 (PLANSPONSOR.com) – A federal court has refused to dismiss a claim by a Jersey Construction employee that he was fired for pursuing health benefits for his wife’s chemotherapy.

The U.S. District Court for the District of New Jersey said it found that Christian Pailleret stated sufficient facts to support a prima facie case under § 510 of the Employee Retirement Income Security Act (ERISA). The court said Pailleret had no “smoking gun” evidence of intent, but the fact that almost immediately after he submitted medical claims of tens of thousands of dollars, he was assigned low-level and “degrading” tasks and shortly after that was terminated without notice or explanation was sufficient to show a plausible claim and “to thus unlock the doors of discovery.” Read more

Davis v. AK Steel Corp., 2009 WL 3853608 (W.D. Pa. 2009)

The trial court in this case found that an employer’s SPD hand-delivery process satisfied DOL regulations, which require that the process be reasonably calculated to ensure that recipients receive SPDs and likely to result in full distribution. The employer had denied an employee’s claim for LTD benefits on the grounds that the employee failed to apply within the plan’s required timeframe. The employee sued claiming, among other things, that he never received the plan’s SPD that would have informed him of the application deadline. Read more

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.

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by John P. McLaughlin and Alexandra Bak-Boychuk of Ballard Spahr Andrews & Ingersoll, LLP, www.ballardspahr.com

Cities and municipalities may recover benefits paid under the Pennsylvania Heart & Lung Act (HLA) through subrogation of an employee’s tort recovery. In City of Wilkes-Barre v. Robert P. Sheils, Jr., the U.S. Court of Appeals for the Third Circuit upheld the common-law right of subrogation to recover such costs from police and fire personnel who obtain a tort recovery from a motor vehicle accident. Read more

Estate of Schwing v. Lilly Health Plan, 2009 WL 989114 (3rd Cir. 2009)

The circuit courts continue to address the U.S. Supreme Court’s Glenn decision on the standard of review applicable in ERISA benefits litigation. The more deferential standard applies if the plan document gives the plan decision maker “discretionary” authority to make benefit decisions. In Glenn, the Supreme Court held that a decision maker’s conflict of interest does not change the standard of review, but must be considered as a factor when applying the abuse of discretion standard. Read more

Generally, well-drafted subrogation and reimbursement provisions allow a health plan to recover benefits paid for medical expenses even if a tort settlement is structured so as to not reimburse the injured party for medical expenses caused by the individual making the settlement. However there are exceptions to this rule if the plan’s subrogation and reimbursement provision is less than perfect. The recent decision in ACS/Primax v. Polan, 2008 WL 5213093 (W.D. Pa., Dec. 12, 2008) illustrates the exception. Read more

In the case of Humana Health Plans, Inc. v. Patti Powell, 07CV385 (W.D. Ky. Feb. 25, 2008), the Western District of Kentucky issued an important decision regarding ERISA preemption of Kentucky Stat. § 441.188. This Kentucky Statute at issue in the case limits a subrogated party’s rights where that party fails to intervene in the state court action. Previously, the Court had decided that this section was not preempted by ERISA, but in this decision the Court reconsidered and reversed itself. Read more

Based on the high volumn of requests, click here to see the entire case.

When negotiations concerning a possible settlement of plaintiff’s subrogation claim failed, Ms. DeBoer demanded her share of the settlement, and the attorney defendants paid over to her the amounts they had recovered, less their counsel fees and expenses. In doing so, they carefully notified Ms. DeBoer of her obligation to repay the plaintiff’s subrogation claim, and obtained from Ms. DeBoer an agreement to indemnify them against any claims which might ensue because they had paid over the proceeds to her. The present lawsuit followed. Read more

The United States District Court for the District of New Jersey, following a hearing on July 24, 2008, has approved a $250 million settlement in the matter of plan members versus Health Net, Inc.  Read more

In Cheryl Street v. Ingalls Memorial Hospital, (2007 U.S. Dist. Lexis 18643), the Northern District Court of Illinois held on March 15, 2007 that just as a Plan must identify funds prior to seeking equitable relief in Federal Court, so too must relief sought by participants be specifically identifiable. In one case, decided by the Third Circuit Court of Appeals, a group of employee Plan Participants brought their Plan Administrator to court for handling their assets in an irresponsible manner. In Eichorn, et al. v. AT&T Corp., et al., 484 F.3d 644, (May 2, 2007), the Court held that while ERISA makes it illegal for a Plan Administrator to prevent the attainment of rights provided by the Plan, actions that lessen the value of the rights are not so prohibited. As such, in a case like this one, the only relief available was in the form of monetary awards and back pay, which is not “equitable relief” for purposes of Federal jurisdiction. Read more