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
Defendant-appellee Ken Ross is the commissioner of the Michigan Office of Financial and Insurance Services (OFIS). OFIS is responsible for licensing, examining, and supervising insurers and nonprofit health care corporations doing business in Michigan. To this end, OFIS’s authority includes the power to disapprove insurance policy forms and documents associated with such forms that are [...]
Adam V. Russo | May 17, 2010
Case: Galion Community Hospital v. Hartford Life & Accident Ins. Co,, No. 1:08-cv-1635, in the United States District Court for the Northern District of Ohio, Eastern Division, May 7, 2010).
Mr. Croft’s Comment: This case involves two arguably conflicting provisions in an advance funding endorsement concerning the timing of submission of requests for advance funding:
To be [...]
Adam V. Russo | February 23, 2010
In Hall v. Liberty Life Assurance Company, No.s 08-4738/4739 (6th Cir. 2010), the plaintiff, . Sonya Hall, had received long-term disability benefits (the “LTD Benefits) for nearly five years through the National City Corporation Welfare Benefits Plan (the “Plan”). Liberty Life Assurance Company of Boston (“Liberty Life”), the third-party claims administrator, terminated the LTD Benefits [...]
Adam V. Russo | February 1, 2010
MyHealthGuide Source: Meredith Z. Maresca, BNA’s Pension & Benefits Daily, 1/27/2010, www.bna.com
In a decision addressing identification of the proper defendant in a benefit claim action brought pursuant to the ERISA’s civil enforcement provision, the U.S. District Court for the Southern District of Ohio held that the health plan’s TPA potentially could be liable for the [...]
Adam V. Russo | January 20, 2010
Sixth Circuit Court of Appeals, No. 04-4067, March 21, 2006
The Sixth Circuit Court of Appeals reversed a district court’s order that a health benefit plan must pay a hospital the full amount billed for services rendered to a plan beneficiary, and remanded for further proceedings.
A beneficiary of South Lorain Merchants Assn. Health & Welfare [...]
Adam V. Russo | November 18, 2009
The law in many states provides that reimbursement to a plan from tort settlements or judgments will not be allowed unless the plan participant is “made whole.” Certainly, the plan participant is not made whole if the settlement or judgment is less than the amount of benefits paid. But even if the settlement or judgment [...]
Adam V. Russo | November 18, 2009
Plan’s subrogation and reimbursement language may actually thwart their ability to recover from tort settlement proceeds benefits they paid. It is important for plan language to ensure that its recovery claim is limited to settlement proceeds. In one such case, a health plan did not identify a particular fund from which the reimbursement should be [...]
Adam V. Russo | November 16, 2009
Please see the following 6th Circuit Decision brought to our attention by Daran P. Keifer, Esq. of Kreiner & Peters Co. L.P.A. The decision highlights that funds do not need to be maintained in order for a plan to seek reimbursement and that the Plaintiff attorney is personally liable for the percentage of reimbursement equal [...]
Adam V. Russo | August 31, 2009
From The Bench – The Self-Insurer Volume 26* August 2009
By John H. Eggertsen, Esq. and Michael Friedman, Esq.
After the U.S. Supreme Court’s recent decision in Metropolitan Life Ins. Co. v. Glenn ___ U.S.___, 128 S. Ct. 2343 (2008), many circuit courts have been applying a magnifying glass to their prior standard of review decisions, and [...]
Adam V. Russo | July 29, 2009
by B. Janell Grenier, The Fiduciary Guidebook, www.fiduciaryguidebook.com
One of the key aspects of determining whether ERISA fiduciary law applies has to do with whether the benefit plan at issue is an ERISA-covered plan. ERISA provides an exemption from its applicability under 29 C.F.R. Section 2510.3-1(j) for certain “group or group-type insurance programs.” If a plan [...]
Adam V. Russo | July 28, 2009
In Wenner v. Sun Life Assurance Co. of Canada, 482 F.3d 878 (6th Cir. 2007), the Sixth Circuit found that Sun Life’s failure to give plaintiff an opportunity to appeal the new grounds for its termination of his benefits violated ERISA’s notice requirements. The insurer initially terminated plaintiff’s benefits because he failed to provide requested [...]
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 | June 25, 2009
by John Wood of ERISA and Disability Benefits Law Blog, www.erisaontheweb.com
Sherry DeLisle continued working after her car crashes in 1998 and 2000. She suffered spinal and closed head injuries. Her employer, Krandall & Sons, fired her on April 17, 2002, stating that “she was not doing her job.” Eight months later, DeLisle filed for long-term [...]
Adam V. Russo | June 10, 2009
In American Council of Life Insurers v. Ross, case, 2009 U.S. App. LEXIS 5748,F.3d (6th Cir. 2009), the Sixth Circuit held that a Michigan law prohibiting insurers from including discretionary language in insurance policies fell within the scope of ERISA preemption “savings clause” and was therefore enforceable. The court relied on the Supreme Court’s Miller [...]
