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 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 | 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…)
Category: 3rd, 4th, 5th, 7th, 9th, DOL, ERISA, Health Insurance, HHS, PPACA, Self-Funding, Stop Loss |
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cmonfils | November 18, 2011
Is the Affordable Care Act constitutional or not?
It seems like every week brings a different wrinkle, if not a new answer.
The Supreme Court will convene on Thursday to decide whether to take up the case against reform. The universal expectation is that the high court will elect to grant certiorari, rather than avoid the lawsuits altogether.
Category: 11th, 4th, 6th, Health Care Legislation |
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cmonfils | October 18, 2011
www.foxnews.com
Published October 10, 2011 | FoxNews.com
A Virginia university is the latest party to request the Supreme Court step in and resolve the multifront legal brawl over the constitutionality of President Obama’s health care overhaul.
Liberty University, a private Christian university founded by the late Jerry Falwell, asked on Monday for the high court to review an appeals court’s decision to dismiss its challenge of the law. (more…)
Category: 4th, Health Care Legislation, Virginia |
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cmonfils | October 13, 2011
www.modernhealthcare.com
By Joe Carlson October 3, 2011
The U.S. Justice Department charted a legal course last week that could produce a final decision on the constitutionality of the Patient Protection and Affordable Care Act in the heat of the 2012 presidential campaign.
Attorneys for the Justice Department filed their formal petition Aug. 28 for oral arguments before the U.S. Supreme Court to appeal a decision from Atlanta’s 11th U.S. Circuit Court of Appeals that the reform law’s mandate for individuals to purchase private insurance was unconstitutional. That same day 26 state governments, a national employers’ rights group and two private citizens—who all oppose the reform law—appealed different aspects of the same decision. (more…)
Category: 11th, 4th, PPACA, Supreme Court |
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cmonfils | September 28, 2011
www.towerswatson.com
September 2011
On procedural and jurisdictional grounds, the U.S. Court of Appeals for the Fourth Circuit dismissed two cases challenging the individual mandate provision in the Patient Protection and Affordable Care Act (PPACA). First, in Virginia ex rel. Cuccinelli v. Sebelius, the Fourth Circuit Court held that Virginia lacked “standing” to bring the lawsuit that the individual mandate was unconstitutional and instructed the district court to dismiss the case. Additionally, in Liberty University Inc. v. Geithner, which challenged not only the individual mandate but also the employer play-or-pay mandate penalty, the Fourth Circuit found a lack of jurisdiction. The appellate court vacated the district court’s decision that had upheld the constitutionality of the individual mandate. The court did not address the constitutional merits of either case. (more…)
Category: 4th, Health Care Legislation |
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cmonfils | September 11, 2011
www.kaiserhealthnews.com Sep 08, 2011
The Virginia case, brought by state Attorney General Ken Cuccinelli, was considered one of the highest profile health law challenges to the health law. In its opinion, issued today, the appellate court ruled that the state does not have standing to challenge the law’s individual mandate because it lacks “a personal stake.” It also concluded that Liberty University’s challenge should be dismissed. (more…)
Category: 4th, Virginia |
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cmonfils | September 9, 2011
Sep 08, 2011
The Virginia case, brought by state Attorney General Ken Cuccinelli, was considered one of the highest profile health law challenges to the health law. In its opinion, issued today, the appellate court ruled that the state does not have standing to challenge the law’s individual mandate because it lacks “a personal stake.” It also concluded that Liberty University’s challenge should be dismissed. (more…)
Category: 11th, 4th, 6th, Health Care Legislation, Virginia |
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cmonfils | August 15, 2011
www.erisalawyerblog.com By Stanley D. Baum August 4, 2011
In Malkani v. Clark Consulting, Incorporated, No. 10-2008 (4th Cir. 2011) (Unpublished Opinion), the Fourth Circuit Court of Appeals reminds us about who can sue under ERISA. (more…)
Category: 4th, ERISA |
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cmonfils | December 29, 2010
www.laborandemploymentlaw.ncbar.org
Article Date: Friday, December 17, 2010
Written By: Robert Ward Shaw & Mark Stanton Thomas
The U.S. District Court for the Eastern District of North Carolina recently held that the Employee Retirement Income Security Act of 1974 (“ERISA”) precludes a plan administrator with a claim against the insured for amounts recovered from a third party for medical benefits from pursuing equitable remedies against the insured attorney’s contingency fee award. (more…)
Category: 4th, Common Fund, Subrogation |
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Adam V. Russo | September 7, 2010
Summary
Federal district court in N.C. favors recovery after lien is dissolved by attorney – Denton is injured and gets a $100,000 settlement, her attorney takes $33,800 of that and disburses the remainder to Denton with a warning that her share could be recovered by the plan. The plan paid $48,250. The plan sued Denton and her attorney to recover. The court awarded the $48,250, but the attorney was not liable just because he disbursed the proceeds; and the proceeds were not traceable in a way similar to what’s now required under Sereboff. The court contrasted this from the 6th Circuit holding in Longaberger Co. v. Kolt (2009), which allowed recovery from a contingency fee paid to an attorney. The court noted the settlement allowed for paying the attorney and the plan with some left over for the participant.
Click here to see the entire case
Category: 4th, 6th, Attorneys' Fees, North Carolina, Reimbursement |
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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.
(more…)
Category: 3rd, 4th, ERISA, Exclusion, Third Party Administrators |
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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 injuries because the insured had expressed a desire to commit suicide in the exact place he was later found dead. Reliance Standard further argued that the insured’s intentional use of prescription drugs contributed to his inability to maintain a clear airway. The court sided with the insurer, citing evidence that the insured “intended to commit suicide, ingested dangerous narcotic medication, and died as a result.” Accordingly, the court concluded that the insurer “reasonably found that [the insured] intended the ultimate result, although he may not have anticipated the exact means.”
Category: 4th, Exclusion, Plan Language |
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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 trailer parked on the side of the road. At the time of the collision, the insured was not wearing his seat belt, and his blood alcohol level was 50 percent higher than the state’s legal limit. For purposes of establishing coverage, the plan defined accident as an “unexpected and sudden event in which the insured does not foresee.” The court determined that absent evidence of an insured’s subjective intent, an “objective analysis” governs whether death was “unexpected” when that term is undefined in accidental death policy. The court found that the circumstances of the insured’s accident were “perfectly consistent with his inebriated state” and noted that “all drivers know, or should know, the dire consequences of drunk driving.” In reaching its decision in favor of the insurer, the court joined what it characterized as “near universal accord that alcohol-related injuries and deaths are not ‘accidental’ under insurance contracts governed by ERISA.”
(more…)
Category: 4th, 7th, Exclusion, Plan Language |
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