cmonfils | December 21, 2011
Self-Insurer December 2011 Issue, Volume 38
By Michael Friedman and John Eggertsen
The subtleties of subrogation Analysis, or when drafting plan Language it is not so simple to say what you mean in a way a court will understand it.
For those who stick with this discussion of the Court’s assessment of the subrogation and reimbursement provisions in Two ERISA Plans, it will become abundantly clear that courts will review such provisions with the proverbial fine tooth comb, and that careful and explicit drafting is required in order for a plan administrator to enforce a plan’s rights. (more…)
Category: 9th, ERISA, HIPAA, Reimbursement, Subrogation |
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cmonfils | November 29, 2011
THIRD CIRCUIT HOLDS THAT ERISA PLANS REIMBURSEMENT CLAIMS ARE SUBJECT TO EQUITABLE DEFENSES AND LIMITATIONS
On November 16, 2011, the Third Circuit held in US Airways, Inc. v. McCutchen, that an ERISA plan’s claims for reimbursement under ERISA §502(a)(3) are subject to equitable limitations and defenses. The matter involved a self-funded ERISA plan which had paid $66,866 on behalf of a plan participant who was injured in an automobile accident. (more…)
Category: 11th, 3rd, 8th, 9th, ERISA, Reimbursement |
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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 9th U.S. Circuit Court of Appeals ordered Blue Shield of California, the plan administrator of an insured ERISA plan, to cover a residential stay for psychological treatment despite plan terms excluding residential stays of any kind. The court even found that Blue Shield gave its plan document a sound reading. California’s Mental Health Parity Act provides coverage for “medically necessary” diagnosis and treatment of “severe mental illnesses,” whether or not it involves a residential stay. The court rejected Blue Shield’s attempt to circumscribe the Parity Act to services listed in that Act and matching the Knox-Keene Act. Then the court held Blue Shield forfeited its right to argue against medical necessity in court because it had not done so in the administrative stage. (more…)
Category: 9th, California, ERISA, Health Insurance, Mental Health Parity |
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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 | October 18, 2011
People with eating disorders like anorexia have opened up a new battleground in the insurance wars, testing the boundaries of laws mandating equivalent coverage for mental illnesses.
Through claims and court cases, those with severe cases of anorexia or bulimia are fighting insurers to pay for stays in residential treatment centers, arguing that the centers offer around-the-clock monitoring so that patients do not forgo eating or purge their meals.
http://www.nytimes.com/2011/10/14/business/ruling-offers-hope-to-eating-disorder-sufferers.html?_r=1&scp=1&sq=Eating%20Disorders%20a%20New%20Front%20in%20Insurance%20Fight&st=cse
Category: 9th, Health Insurance |
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cmonfils | September 16, 2011
The Self-Insurer August 2011
From the Bench Michael Friedman and John Eggertsen
The U.S. Supreme Court, in GIGNA Corp v. Amara, et al., 563 U.S., 2011 WL 1936077 (May 16, 2011), revisited, and likely expanded, the scope of equitable remedies available under ERISA § 502 (a)(3). The Court also rejected Plaintiff’s effort to sue under the terms of the SPD as opposed to the terms of the actual ERISA plan document. (more…)
Category: 2nd, 9th, ERISA, Summary Plan Description, Supreme Court |
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cmonfils | August 22, 2011
The Self-Insurer August 2011
From the Bench Michael Friedman and John Eggertsen
The U.S. Supreme Court, in GIGNA Corp v. Amara, et al., 563 U.S., 2011 WL 1936077 (May 16, 2011), revisited, and likely expanded, the scope of equitable remedies available under ERISA § 502 (a)(3). The Court also rejected Plaintiff’s effort to sue under the terms of the SPD as opposed to the terms of the actual ERISA plan document. (more…)
Category: 9th, ERISA, Summary Plan Description, Supreme Court |
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cmonfils | July 11, 2011
Matthiesen, Wickert & Lehrer, S.C. June 2011 Newsletter
Matthiesen, Wickert & Lehrer, S.C. (MWL) has authored and filed an amicus curiae brief on behalf of the National Association of Subrogation Professionals (NASP) in the 9 Circuit case th of CGI Technologies and Solutions, Inc. Welfare Benefit Plan v. Rhonda Rose and Nelson Langer Engle, PLLC. Ryan Woody and Tim Mentkowski authored the brief, which turned out to be a powerful defense of subrogation generally, and health insurance subrogation specifically. (more…)
Category: 9th, Legal |
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cmonfils | July 11, 2011
www.fordharrison.com 6/29/2011
Executive Summary: Specifically overruling the holdings of four prior decisions, a full panel of the Ninth Circuit has held that ERISA permits the beneficiaries of an employee benefits plan to sue parties other than the plan administrator to recover benefits due under the plan. See Cyr v. Reliance Standard Life Insurance Company (9th Cir. June 22, 2011). (more…)
Category: 9th, ERISA |
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cmonfils | July 4, 2011
www.workforce.com June 27, 2011
The 9th U.S. Circuit Court of Appeals circuit court June 23 decided that retirement-plan participants can sue third-party insurers under the Employee Retirement Income (more…)
Category: 9th, ERISA |
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cmonfils | May 3, 2011
Coordination of Benefits April 2011 | Vol. 19, No. 2
It is well established that a health plan subject to ERISA can recover the benefits it paid from identifiable tort settlement proceeds held by the plan participant’s attorney. When those proceeds are identifiable as to their source an equitable lien can be asserted against the proceeds. If a self-funded ERISA health plan is subject to the common fund rule, both the attorney and the plan would have to share client’s attorney’s fees, and each of them would bear a pro rata share of the tort settlement proceeds (that is, the common fund). (more…)
Category: 9th, California, Common Fund |
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cmonfils | March 25, 2011
www.sfgate.com
Thursday, March 17, 2011
ERISAclaim.com announced 2011 free webinars to examine a recent federal appeals court decision, USA v. Eriksen, (9th Cir. Case:10-30056, ID:7673525, 03/09/2011), affirming the ERISA Embezzlement Convictions against two defendants administering a 401(k) plan, as a part of its new Plan Assets Recovery & Audit Programs to assist self-insured health plans in fiduciary compliance and plan assets recovery. The new Webinars will examine the Court Decision’s impact, along with recent DOL Contributory Plans Criminal Project, on ERISA Health Plan Overpayment Recoupment Market, in case of any TPA’s failure to remit recovered plan assets from healthcare providers to the self-insured ERISA plans and failure to report recouped plan assets to DOL and IRS on 5500 Forms, in a healthcare industry with an estimated recouped plans assets in billions of dollars. (more…)
Category: 9th, ERISA, Provider Reimbursement |
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cmonfils | March 18, 2011
www.healthplanlaw.com Roy Harmon III
March 15, 2011
It is well-established that ERISA plan participants and beneficiaries may assign their rights to their health care provider. Misic v. Bldg. Serv. Employees Health & Welfare Trust, 789 F.2d 1374, 1378-79 (9th Cir. 1986). As an assignee, the provider has standing “to assert the claims of his assignors.” Id. at 1379. A Plan may also prohibit the assignment of rights and benefits. Davidowitz v. Delta Dental Plan of California, Inc., 946 F.2d 1476 (9th Cir. 1991). Both the Braun and Rudolph Plans prohibit the assignment of benefits. (more…)
Category: 9th, Attorneys' Fees |
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cmonfils | January 12, 2011
www.healthsubrogationblog.com
Posted on January 6, 2011 by Tom Lawrence
After Sereboff, many of us who practice regularly in this area believed that the “races to the courthouse” to obtain TROs and injunctions post-Knudson were over and that life would return to the “good ole days” of arguing with personal injury attorneys about whether our plan language was sufficient to override the federal common law make-whole rule and/or common fund doctrine in that particular circuit. On December 29, 2010, the Ninth Circuit brought us back to reality. (more…)
Category: 9th, Subrogation |
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Adam V. Russo | October 29, 2010
By Stephen D. Rosenberg of Boston ERISA & Insurance Litigation Blog, www.bostonerisalaw.com
Well, here’s a story on an unpublished Ninth Circuit decision on the impact on the duty to defend of related claims provisions in claims made insurance policies. Although policies vary in the language and structure they use to accomplish it, these provisions essentially declare a claim made during a policy period to be linked to earlier events or an earlier claim if they all arise from related events, with there being no coverage if the earlier related events occurred before the policy period of the policy under which coverage is being sought. The operation of these provisions is of crucial importance for the operation of claims made insurance policies and for insurance programs built on them, in that a claims made policy is built around the idea that the policy will only provide coverage for claims – such as lawsuits – actually first made against the insured during the effective period of that policy, and that the policy won’t provide any coverage if the loss for which coverage is sought relates to a claim that began before the commencement of that policy period. Claims made policies are priced on only covering claims actually first arising during the policy period – and not on covering those that started before the policy period or were not made until after it ended. By precluding coverage when a particular claim actually stems from events or another claim that predated the policy, the related acts language is the mechanism for effectuating this intent. I will warn you up-front that this is a very simplistic introduction to a fairly complicated subject, but it captures the idea. (more…)
Category: 9th, Claims Review |
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