Adam V. Russo | March 24, 2009
Since the Glenn decision, a number of circuits have had an opportunity to consider and apply the Glenn Court’s reassessment of ERISA’s standard of review.Roumeliote v. LTD Plan for Employees of Worthington Industries, 298 Fed. Appx. 472 (6th Cir. 9/11/2008).
This was the first circuit to apply Glenn since Glenn was a Sixth Circuit decision and the Sixth Circuit’s determination in that case was affirmed by the Supreme Court. The Sixth Circuit affirmed the district court’s decision that the claim administrator’s denial of benefits was not arbitrary. (more…)
Category: 11th, 4th, 6th, 9th |
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Adam V. Russo | March 23, 2009
by Jerry Geisel of Business Insurance
San Francisco- The 9th U.S. Circuit Court of Appeals’ decision last week not to review a 2008 appeals panel ruling upholding a San Francisco health care spending law brings one step closer to a potential U.S. Supreme Court review and perhaps a final resolution on the legality of employer spending mandates.
In a case followed by employers nationwide due to its potential impact on the design, cost and administration of corporate health plans, a majority of appeals court members rejected a request for the full appeals court to review a unanimous ruling by a three-judge panel of the court that the law could stand. (more…)
Category: 9th |
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Adam V. Russo | March 19, 2009
From the Clear Direction Blog www.cleardirectionblog.com
Posted: 18 Mar 2009
A recurring issue for health plan subrogators is what language is sufficient to override the make whole rule. On the one hand, Circuits like the Fifth Circuit have held that no particular language is required to overcome the make whole rule. In the Fifth Circuit (and others like it), plan language simply providing for 100% recovery is sufficient. (more…)
Category: 9th, Made Whole Rule, Summary Plan Description |
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Adam V. Russo | December 4, 2008
I recently received an email from a colleague of mine, James R. McKown, CEO of Recovery Data Connect, L.L.C., notifying me about a 9th circuit decision emphasizing three major factors in the case: plan language creating an automatic lien, rejecting the Made Whole Doctrine and preventing the plaintiff from challenging related medical claims due to a Sworn Declaration. To read the entire 9th circuit decision, Laborers v. Hill, United States District Court for the Northern District of California (November 25, 2008). Click Here
Category: 9th |
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Adam V. Russo | November 6, 2008
TPAs rely heavily on ERISA’s requirements that claimants must exhaust their administrative remedies before going to court, and when they do sue, assuming that the Plan documents grant the claim administrator the appropriate discretionary authority, they must show that the claim administrator abused its discretion when denying their claim, before any court will get to the merits of their allegations.
Few plaintiffs are able to meet these burdens, and so either don’t sue or often get their lawsuits quickly dismissed. Until recently most courts were not very sympathetic to plaintiffs’ arguments of procedural violations, but things are changing, the most significant development being the Supreme Court’s decision this summer in MetLife v. Glenn. (more…)
Category: 7th, 9th, Claims Procedures, Claims Review |
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Adam V. Russo | October 29, 2008
Latest Article From AM News Staff
By Amy Lynn Sorrel
The decision could lay the groundwork for a U.S. Supreme Court fight over “pay or play” laws requiring companies to pitch in for health coverage.
A recent federal appeals court ruling may open the door for states looking to experiment with employer mandates as part of health system reform.
A panel of the 9th U.S. Circuit Court of Appeals unanimously upheld San Francisco’s initiative requiring businesses to spend a minimum level of money on workers’ health care, rejecting arguments that the federal Employee Retirement Income Security Act preempted the city ordinance. (more…)
Category: 9th |
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Adam V. Russo | October 6, 2008
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. (more…)
Category: 9th |
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Adam V. Russo | October 3, 2008
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. (more…)
Category: 9th, California, ERISA |
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Adam V. Russo | October 3, 2008
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. (more…)
Category: 9th, ERISA, Preemption |
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Adam V. Russo | July 14, 2008
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. (more…)
Category: 9th, California, Preemption |
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Adam V. Russo | June 9, 2008
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. (more…)
Category: 9th, Coordination of Benefits, Plan Language, Subrogation |
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Adam V. Russo | June 6, 2008
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. (more…)
Category: 9th, California, Preemption |
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Adam V. Russo | May 6, 2008
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.)). (more…)
Category: 9th |
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Adam V. Russo | April 22, 2008
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. (more…)
Category: 5th, 9th, Made Whole Rule, Summary Plan Description |
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Adam V. Russo | April 22, 2008
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. (more…)
Category: 9th, Special Needs Trust |
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