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 | 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
Employer’s Guide to Self-Insuring Health Benefits October 2011 | Vol. 19, No. 1
A federal appeals court lined up with two lower court rulings in deciding that a hospital and a physician practice were not liable under ERISA to return money to a plan that mistakenly paid claims for a plan member’s ineligible daughter.
The 7th U.S. Circuit Court of Appeals said because the child was never enrolled in the plan, the plan’s suit to enforce ERISA rights or duties could not work, in Kolbe & Kolbe Health and Welfare Ben. Plan v. Medical College of Wisconsin, Inc., 2011 WL 3873773 (7th Cir., Sept. 2, 2011). (more…)
Category: 7th, ERISA, Overpayment |
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cmonfils | August 31, 2011
www.erisalawyerblog.com
August 24, 2011 By Stanley D. Baum
In Kough v. Teamsters’ Local 301 Pension Plan, No. 10-2128 (7th Cir. 2011) (Nonprecedential Opinion), the plaintiff had suffered a disability, and then returned to work in 2005. He soon (in that year) suffered a heart attack and abandoned his attempt to work. He filed a claim for disability benefits under a union pension plan subject to ERISA (the “Plan”), but the claim was denied by the Plan. The plaintiff then filed this suit. (more…)
Category: 7th, ERISA |
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cmonfils | July 27, 2011
Facts:
Participant of an ERISA covered Plan had an accident and filed an action in Wisconsin wherein he named the Plan as a defendant and disputed Plan’s rights under the Made Whole Rule. Plan then filed a cross claim against defendant parties and a counter claim against member asserting made whole inapplicable due to plan language. Plan participant settled with defendant party including a surgery he consistently related to the accident and never advised plan of settlement negotiations. Subsequent to that settlement, he claimed there was an IME showing the surgery was not related to the accident. (more…)
Category: 7th, Made Whole Rule, Wisconsin |
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cmonfils | May 16, 2011
www.healthplanlaw.com Roy Harmon III May 12, 2011
Defendants argue that the first amended complaint is deficient because, with the exception of Count Four, which is identified as a claim for benefits pursuant to §1132(a)(1)(B), plaintiff fails to specify the ERISA statutory provisions upon which her claims are based. This argument is not well taken. (more…)
Category: 6th, 7th, Plan Language |
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cmonfils | March 18, 2011
www.chiroeco.com
March 14, 2011 — The International Chiropractors Association (ICA) announced today that its claims challenging the overpayment recovery practices of various Blue Cross Blue Shield entities were upheld by Judge Matthew F. Kennelly of the United Stated District Court in Chicago, IL, in Pennsylvania Chiropractic Association, et al. v. Blue Cross Blue Shield Association, et al., Case No. 1:09-cv-05619. (more…)
Category: 7th, Illinois, Provider Reimbursement |
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cmonfils | March 1, 2011
www.healthplanlaw.com
February 21, 2011 • Roy Harmon III
In Comrie v. IPSCO (7th. Cir. 2/18/11) the Seventh Circuit considered whether a discretion-conferring clause in a SERP plan document should be applied when the plan administrator is not a fiduciary. Noting a difference of opinion on the issue, the Seventh Circuit, via Judge Easterbrook, saw the issue as very simple to resolve: (more…)
Category: 7th, 8th, ERISA |
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Adam V. Russo | July 9, 2010
In addressing the contents of the administrative record that must be disclosed to a claimant, the court in Mondry v. American Family Mutual Insurance Co. concluded that a claim administrator’s internal documents and guidelines could be subject to mandatory production in ERISA cases if the claims administrator expressly cites to such documents and equates them to plan language when ruling on a claim for benefits. The letters denying plaintiff’s claim for benefits cited documents other than the SPD as the basis for the plan’s denial of her claim, and the reasoning behind the denials turned on language that did not appear in the SPD. The claims administrator initially refused to produce the documents requested by plaintiff, even when the plan administrator intervened on her behalf, but eventually relented. The documents showed that denial of plaintiff’s claim was improper and the claims administrator reversed it. The court further found that the plan administrator, even though it did not have direct control over the documents, could be liable for failing to produce them because it could have included in its contract with the claims administrator the right to obtain copies of any documents that it might be required to produce under ERISA. The Seventh Circuit also confirmed the documents at issue fell within scope of 29 U.S.C. § 1024(b)(4) and held that a plan fiduciary that fails to make the disclosures required by ERISA breaches its fiduciary duties to a participant like plaintiff.
Category: 7th, ERISA |
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Adam V. Russo | July 9, 2010
Juli Pollitt, a federal employee, had health insurance administered by Health Care Service Corp. (HCSC). In July 2007, HCSC stopped paying claims submitted on behalf of Pollitt’s son Michael and began trying to collect from health care providers any payments made on Michael’s behalf since 2003. According to HCSC, it did this because the Department of Labor, which tells HCSC which federal employees have what coverage, instructed HCSC that Pollitt’s coverage was for herself only rather than for herself and her family. According to Pollitt’s complaint in this suit, however, HCSC reached this conclusion on its own because the Department of Labor had failed to pay the appropriate premium into a fund that covers the expense of the medical benefits. Instead of checking with the department or with her, Pollitt’s complaint alleged, HCSC abruptly stopped covering Michael’s medical expenses and made demands for reimbursement that subjected her family to humiliation and expense. Just as abruptly, HCSC changed course in October 2007 and started paying the claims again. But even then, Pollitt asserted, HCSC did not inform medical providers, who continued trying to collect from Pollitt the back payments they thought HCDC was dunning them for. (more…)
Category: 7th, Claims Procedures, Claims Review, Exclusion |
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Adam V. Russo | June 21, 2010
www.plansponsor.com
June 8, 2010 (PLANSPONSOR.com) – The U.S. District Court for the Western District of Wisconsin has found that an employer did not breach its fiduciary duties by failing to inform a former employee and his wife about all of their benefit options. (more…)
Category: 7th, Federal Circuits, Summary Plan Description, Wisconsin |
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Adam V. Russo | January 4, 2010
In Majeski v. Metropolitan Life Insurance Co., No. 09-1930 (7th Cir. 2009), the plaintiff, Kirsten Majeski, had been employed by Metropolitan Life Insurance Company (“MetLife”), and had participated in MetLife’s Short Term Disability Plan (the “Plan”).
The case centers on the decision of MetLife, as plan administrator, to reject Majeski’s claim for short-term disability benefits, after determining that Majeski had failed to submit enough evidence to support her claim. The district court had likewise rejected Majeski’s claim for the benefits and had granted summary judgment against her. (more…)
Category: 7th |
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Adam V. Russo | November 18, 2009
When it is clear that the tort settlement proceeds are held in a separate account and the plan clearly provides for 100-percent reimbursement, the fact that the plan beneficiary is a minor child will not preclude the plan’s entitlement to reimbursement. The case is Iowa Health System, Inc. v. Graham, 2009 WL 2222780 (C.D. Ill., July 23, 2009). (more…)
Category: 7th, Minor's Compromise |
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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 paid and it failed to say that the recovery was limited to third-party settlement proceeds. Because of the imprecise drafting, the court could assume the plan was trying to recover from the plan participant’s general assets. That created the possibility that a member could receive a recovery from a third party that was less than the benefit paid by the plan but would still have to repay the plan in full. As a result, the court found it impossible to award the recovery. (more…)
Category: 6th, 7th, Subrogation, Summary Plan Description |
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Adam V. Russo | November 18, 2009
By Stanley D. Baum – Erisalawyerblog.com
In Wetzler v. Illinois CPA Society & Foundation Retirement Income Plan, No. 08-2923 (7th Cir. 2009), the plaintiff, Thomas Wetzler, wanted a lump-sum payment of his entire retirement benefit from the Illinois CPA Society & Foundation Retirement Income Plan (the “Plan”). The Plan is a tax-qualified defined benefit pension plan. The plaintiff was a highly compensated employee. The Plan had always allowed lump-sum payments. However, prior to the plaintiff’s retirement, the Plan had been amended to reflect certain provisions of the Internal Revenue Code (the “Code”) and the underlying Treasury regulations, under which the Plan could not make a lump- sum payment to certain highly compensated employees, such as the plaintiff, when the Plan is not sufficiently funded (the “Amendment”). At the time of the plaintiff’s request for a lump-sum payment, there were not enough assets in the Plan to cover this payment. Therefore, honoring the plaintiff’s request would have caused the Plan to use all of its assets and violate the Code and the underlying Treasury regulations, and to also violate the Plan itself due to the Amendment. Explaining this to the plaintiff, the plan administrator for the Plan (the “Plan Administrator”) refused his request. The plaintiff filed suit in district court, alleging that the Amendment violated the anti-cutback rules of ERISA (found in 29 U.S.C. § 1054(g)) by eliminating a previously available benefit, and that the Plan Administrator acted arbitrarily and capriciously in denying his demands for a lump-sum payment. The district court granted summary judgment in favor of the defendant, and the plaintiff appealed. (more…)
Category: 7th, ERISA |
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