Archive for the ‘8th’ Category

This is a huge win for the subrogation industry.

The court held that Sereboff, rather than Knudson, controlled in this case. Like in Sereboff, the Plan targeted specific funds for recovery , Cusson’s LTD payments, and identified the specific portion to which Liberty is entitled— the amount of the overpayment while Cusson was receiving benefits under the LTD Plan. Read more

In Iowa Health Systems v. Graham, 2009 U.S. Dist. LEXIS 63544 (C.D. Ill. July 23, 2009), Iowa Health wants the Court to impose a constructive trust or equitable lien over a portion of specifically identifiable funds over which Graham has possession. Read more

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. 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

The Supreme Court’s opinion in Black & Decker Disability Plan v. Nord, 538 U.S. 822(2003) did not hold that treating physician opinions can be neglected.  This recent Eighth Circuit opinion demonstrates an application of an important piece of the Nord decision – that the administrator must take into account treating physicians’ opinions in reaching its conclusions. Read more

The U.S. District Court in North Dakota recently sorted out conflicting COB provisions of motor vehicle and health coverage. The court ruled that the motor vehicle policy had to pay its maximum benefits before the health plan began paying its benefits.  In the North Dakota case, an auto policy restricted benefits to $5,000 in the event the policyholder is covered by another policy; the health plan mandated that the auto insurer must pay up to its policy limit before the plan would begin paying. The court upheld the health plan’s decision. Read more

In two separate cases, courts have found that health plans may refuse to pay benefits if participants or their attorneys refuse to sign reimbursement agreements.  Some attorneys refuse to sign such agreements because they believe the plan is not entitled to fulfill reimbursement under applicable law.  However, in many cases, the plan then refuses to pay any further benefits.  The two cases are Cossey v. Associates Health and Welfare Plan, 2008 WL 276282 (E.D. Ark., Jan. 30, 2008) and Metal Technologies v. Ramirez, 2008 WL 153534 (E.D Wis., Jan 11, 2008).   Read more