cmonfils | December 2, 2011
Applying the traditional equitable principle of unjust enrichment, we conclude that the judgment requiring McCutchen to provide full reimbursement to US Airways constitutes inappropriate and inequitable relief. Because the amount of the judgment exceeds the net amount of McCutchen’s third-party recovery, it leaves him with less than full payment for his emergency medical bills, thus undermining the entire purpose of the Plan. At the same time, it amounts to a windfall for US Airways, which did not exercise its subrogation rights or contribute to the cost of obtaining the third-party recovery. Equity abhors a windfall. See Prudential Ins. Co. of America v. S.S. American Lancer, 870 F.2d 867, 871 (2d Cir. 1989).
Category: 3rd, Subrogation |
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cmonfils | November 30, 2011
The US Court of Appeals for the Third Circuit held that, under ERISA Section 502(a)(3), an employee benefit plan was not entitled to full reimbursement for medical expenses it incurred on behalf of a participant and was limited by equitable principles and defenses to “appropriate” relief, despite plan language specifying full reimbursement. In its decision in US Airways v. McCutchen, the court held that the plan could not recover the full cost of the participant’s medical expenses when the participant recovered less from a third party.
Category: 3rd, ERISA, Reimbursement |
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cmonfils | November 30, 2011
In a case of significant importance for plan sponsors and fiduciaries, the U.S. Court of Appeals for the Third Circuit held in US Airways, Inc. v. McCutchen, No. 10-3836 (3d Cir. Nov. 16, 2011), that an employee benefit plan was not entitled to full reimbursement of medical expenses it paid to a participant even though the plan provided that the participant was required to reimburse the plan for all amounts paid “out of any monies recovered from a third party.” The Court found that, because the participant had not received a complete recovery for his injuries in collateral litigation, full reimbursement to the plan would not be consistent with the terms of Section 502(a)(3) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132(a)(3), which limits recovery to “appropriate equitable relief.”
Category: 3rd, ERISA, Reimbursement |
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cmonfils | November 29, 2011
www.myhealthguide.com
MyHealthGuide Source: Agnes Mendoza-Ben-Yosef, 11/17/2011, BNA Pension & Benefits Daily Article via The Gibson Firm, LLC
Case: US Airways Inc. v. McCutchen, 3d Cir., No. 10-3836, 11/16/11. Court’s Opinion
Article referred by John H. Eggertsen, Esq., Eggertsen Consulting, P.C.
US Airways Inc.’s health benefit plan is not entitled to full reimbursement from an insurance settlement for the medical costs it paid on behalf of a plan participant because the recovery would exhaust the participant’s entire settlement, the U.S. Court of Appeals for the Third Circuit ruled Nov. 16 in the above case. (more…)
Category: 3rd, ERISA, Reimbursement |
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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 | November 18, 2011
Is the Affordable Care Act constitutional or not?
It seems like every week brings a different wrinkle, if not a new answer.
The Supreme Court will convene on Thursday to decide whether to take up the case against reform. The universal expectation is that the high court will elect to grant certiorari, rather than avoid the lawsuits altogether.
Category: 11th, 4th, 6th, Health Care Legislation |
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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 | October 18, 2011
www.benefitlink.com
(From the October 10, 2011 issue of Deloitte‘s Washington Bulletin, a periodic update of legal and regulatory developments relating to Employee Benefits.)
A recent Eighth Circuit Court of Appeals case illustrates the complexity of determining whether an employment agreement is an ERISA plan, and the impact of that decision on the employee’s ability to bring suit. In a case of first impression for the Eighth Circuit, the Court ruled that as matter of law a one-person, individually-negotiated employment agreement is not an ERISA plan. (more…)
Category: 8th, ERISA |
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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 | October 18, 2011
www.foxnews.com
Published October 10, 2011 | FoxNews.com
A Virginia university is the latest party to request the Supreme Court step in and resolve the multifront legal brawl over the constitutionality of President Obama’s health care overhaul.
Liberty University, a private Christian university founded by the late Jerry Falwell, asked on Monday for the high court to review an appeals court’s decision to dismiss its challenge of the law. (more…)
Category: 4th, Health Care Legislation, Virginia |
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cmonfils | October 13, 2011
www.modernhealthcare.com
By Joe Carlson October 3, 2011
The U.S. Justice Department charted a legal course last week that could produce a final decision on the constitutionality of the Patient Protection and Affordable Care Act in the heat of the 2012 presidential campaign.
Attorneys for the Justice Department filed their formal petition Aug. 28 for oral arguments before the U.S. Supreme Court to appeal a decision from Atlanta’s 11th U.S. Circuit Court of Appeals that the reform law’s mandate for individuals to purchase private insurance was unconstitutional. That same day 26 state governments, a national employers’ rights group and two private citizens—who all oppose the reform law—appealed different aspects of the same decision. (more…)
Category: 11th, 4th, PPACA, Supreme Court |
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cmonfils | October 6, 2011
www.foxnews.com
Published September 26, 2011 | Associated Press
The Obama administration has decided not to ask a federal appeals court in Atlanta for further review of a ruling striking down the centerpiece of President Barack Obama’s sweeping health care overhaul. (more…)
Category: 11th, Health Care Legislation |
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cmonfils | September 28, 2011
www.uslf.practicallaw.com
Resource type: Legal Update: Archive
Status: Published on 15-Aug-2011
Jurisdiction: USA
In Dakota, Minnesota & Eastern Railroad Corporation v. Schieffer, the US Court of Appeals for the Eighth Circuit ruled that a one-person employment contract is not a plan under the Employee Retirement Income Security Act (ERISA). However, the court held that a federal court may still have jurisdiction over portions of the complaint and remanded the case with instructions for addressing ERISA preemption. (more…)
Category: 8th, ERISA |
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