Archive for the ‘9th’ Category

The Ninth Circuit has a decision of first impression concerning issue exhaustion and ERISA in the denial of benefits context.  In Vaught v. Scottsdale Healthcare (9th Cir 09/29/2008), the Ninth Circuit declined to impose an “issue exhaustion” requirement under ERISA.

Vaught sued his healthcare plan under ERISA asserting a claim challenging the plan’s decision denying his claim for benefits.  The trial court granted summary judgment in favor of the plan.  The 9th Circuit reversed as to that claim. Read more

In a decision that could set the stage for a test of the supremacy of a longstanding federal labor law, a panel of federal judges found Tuesday that San Francisco had the right to charge employers to help pay for its universal health care plan, the first in the nation.

The ruling, by a three-judge panel of the United States Court of Appeals for the Ninth Circuit, affirms a January decision by the same panel that required all but the smallest businesses in the city to contribute to employees’ health care costs or pay a fee to help the city provide care.  San Francisco officials hailed the decision as a major victory for its plan, called Healthy San Francisco, to provide health care for some 73,000 uninsured residents. Read more

The parents of a minor child sued their health plan insurer when it denied their daughter’s claims for benefits.  The parents argued that the insurer failed to comply with a state external review law for insurers, which required an independent review process for denied claims. The insurer asked the court to dismiss the claim, arguing that the state external review law was preempted by ERISA. Read more

In the matter of Sgro v. Danone Waters of North America, Inc., 2008 U.S. App. LEXIS 13973 (9th Cir. Jul. 2, 2008), an employee - Mitchell Sgro - applied for benefits from his employer’s ERISA Plan.  He incurred $412.00 in copying fees, in the process of supplying documentation and medical records to his employer as part of his claim. Read more

Cooper v. Premera Blue Cross, Slip Copy, 2008 WL 2180148 (W.D.Wash.) (May 23, 2008) addresses a risk often overlooked by plan participants when debating over their benefit plan’s right of reimbursement from other liable insurance carriers.

Cooper suffered multiple injuries while he was a passenger involved in an ATV accident and applied for benefits through his own auto carrier, Allied Insurance, because the driver’s vehicle was uninsured.  Cooper received $64,200 for medical expenses and lost wages through his PIP and UM coverage. Read more

In July of 2006 the San Francisco Health Care Security Ordinance (”the Ordinance”) allowing the city to mandate employers with more than 50 employees to pay a fee to help cover their employee health care costs was unanimously passed by the San Francisco Board of Supervisors. 

On December 26, 2007, the U.S. District Court for the Northern District of California, ruled in favor of The Golden Gate Restaurant Association’s (GGRA) application, contending that ERISA preempted the Ordinance.  Read more

Although Lumbermens Mutual Casualty Company’s Summary Plan Description (”SPD”) clearly states that its Plan Administrator, Kemper Ins., has the discretionary authority to determine eligibility for disability benefits and to interpret the terms of the plan, both the District Court and Ninth Circuit Court of Appeals applied a de novo standard of review, instead of a deferential standard of review in this case, since Lumbermens violated ERISA regulations by failing to properly distribute the SPD to its plan participant, Linda Gertjejansen, (Gertjejansen v. Kemper Ins. Companies, Inc., Slip Copy, 2008 WL 1787484 (C.A.9 (Cal.)). Read more

If the summary plan description (SPD) omits important provisions, such as subrogation and reimbursement, that are included in another document, the plan may not be able to compel beneficiaries to follow those provisions. In one such case, a federal judge shot down a plan’s denial after a participant refused to sign a subrogation agreement. The plan tried to impel him to sign the agreement before he had been treated for his injuries, but the SPD was silent on the issue of executing the agreement before submitting a claim. The plan document had the requirement that members must “execute and deliver such instruments and take such actions as the Plan may require to protect the Plan’s rights.” The court rejected plan arguments that inclusion of such language in the plan document complied with ERISA. Read more

Federal courts are permitting ERISA plans to recover the benefits they paid on account of injuries arising through the fault of some third party from tort settlement or judgment proceeds that are set up in special needs trusts. Those are usually designed to provide resources to pay for ongoing care when an individual’s injuries are so severe that he or she will need professional care either for the remainder of his or her life or for an indefinite period.

In the absence of such a resource, in most cases, individuals will be cared for through state programs such as Medicaid. When a tort settlement or judgment is substantial, the special needs trust can provide some (or perhaps even all of the required care. Or, trusts might be used to provide some amenities (such as TV or other entertainment or respites) for the injured party. Read more

Supreme Court Justice Anthony M. Kennedy declined an application for a continuance of the San Francisco ordinance that sets minimum levels of spending by employers on health care. SEE COURT ORDER

The Golden Gate Restaurant Association asked the Supreme Court to vacate the 9^th Circuit panel’s stay of a district court decision invalidating the ordinance.  The requested stay would prevent enforcement of the ordinance during the period leading up to a decision by the Ninth Circuit on the matter. Read more