Adam V. Russo | April 29, 2010
This case is extremely important as it stands for premise that the Plan expects premium payments and subro rights in exchange for paying benefits. Specifically, it states that subrogation defrays health insurance costs. The Defense made an argument stating that Zurich’s claim for reimbursement violates ERISA’s anti-discrimination provision but Court disagreed stating that plan language applied to all participants. This is a great case to read and cite as it brings us bases from many Circuits – even Shank. Enjoy!!
View the article here. Zurich Vs. O’Hara
Category: 11th, ERISA, Federal Circuits, Subrogation |
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Adam V. Russo | April 12, 2010
By Andrew Jensen Alaska Journal of Commerce
As debate raged over death panels and doctors’ fixes during the last year, a quiet battle was fought behind the scenes to preserve the ability of employers to continue paying their own health care costs.
Known as self-insurance but more accurately as self-funded plans, a substantial number of companies choose to pay their employee health care expenses directly out of their own general funds rather than buy a group plan from a private insurance company. (more…)
Category: 9th, ERISA, Health Care Legislation |
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Adam V. Russo | February 23, 2010
In Hall v. Liberty Life Assurance Company, No.s 08-4738/4739 (6th Cir. 2010), the plaintiff, . Sonya Hall, had received long-term disability benefits (the “LTD Benefits) for nearly five years through the National City Corporation Welfare Benefits Plan (the “Plan”). Liberty Life Assurance Company of Boston (“Liberty Life”), the third-party claims administrator, terminated the LTD Benefits when it determined that Hall was no longer totally disabled. The Plan then sought reimbursement for overpayment of the LTD Benefits, caused by retroactive Social Security benefits being awarded to Hall. Hall responded by filing suit against the Plan. (more…)
Category: 6th, ERISA, Federal Circuits |
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Adam V. Russo | February 1, 2010
MyHealthGuide Source: Meredith Z. Maresca, BNA’s Pension & Benefits Daily, 1/27/2010, www.bna.com
In a decision addressing identification of the proper defendant in a benefit claim action brought pursuant to the ERISA’s civil enforcement provision, the U.S. District Court for the Southern District of Ohio held that the health plan’s TPA potentially could be liable for the alleged wrongful denial of benefits to cover a beneficiary’s bone cancer treatment. (more…)
Category: 6th, ERISA, Ohio |
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Adam V. Russo | January 29, 2010
January 22, 2010 (PLANSPONSOR.com) – A federal court has refused to dismiss a claim by a Jersey Construction employee that he was fired for pursuing health benefits for his wife’s chemotherapy.
The U.S. District Court for the District of New Jersey said it found that Christian Pailleret stated sufficient facts to support a prima facie case under § 510 of the Employee Retirement Income Security Act (ERISA). The court said Pailleret had no “smoking gun” evidence of intent, but the fact that almost immediately after he submitted medical claims of tens of thousands of dollars, he was assigned low-level and “degrading” tasks and shortly after that was terminated without notice or explanation was sufficient to show a plausible claim and “to thus unlock the doors of discovery.” (more…)
Category: 3rd, Claims Procedures, Conflict of Interest, Federal Circuits, New Jersey |
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Adam V. Russo | January 25, 2010
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. (more…)
Category: 1st, 8th, ERISA |
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Adam V. Russo | January 20, 2010
Sixth Circuit Court of Appeals, No. 04-4067, March 21, 2006
The Sixth Circuit Court of Appeals reversed a district court’s order that a health benefit plan must pay a hospital the full amount billed for services rendered to a plan beneficiary, and remanded for further proceedings.
A beneficiary of South Lorain Merchants Assn. Health & Welfare Benefit Plan and Trust (the “Plan”) was admitted to University Hospital of Cleveland (“UHC”) in 2000. For services rendered, UHC sent a bill in the amount of $195,000 to the Plan. Without notifying UHC, the Plan audited the bill and provided payment in the amount of $107,000, a reflection of both a $49,000 preferred provider network discount (“Discount”) and the audit’s finding that the charges exceeded the usual, customary and reasonable (“UCR”) amount for such services by $39,000. (more…)
Category: 6th, Federal Circuits, Usual and Customary |
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Adam V. Russo | January 8, 2010
January 6, 2010 • HealthPlanLaw.com
While similar to the Butero test, Davila refines Butero by inquiring about the existence of a separate legal duty, which is not a consideration under Butero.
Moreover, a number of other circuits have recognized Davila’s two-part test as the proper test for complete preemption under ERISA . . . In accordance with the Supreme Court’s directive, we too apply Davila.
Conn. State Dental Ass’n v. Anthem Health Plans, Inc., 2009 U.S. App. LEXIS 28773 (11th Cir. Fla. Dec. 30, 2009) (more…)
Category: 11th, ERISA, Federal Circuits, Health Care Legislation |
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Adam V. Russo | January 4, 2010
In Majeski v. Metropolitan Life Insurance Co., No. 09-1930 (7th Cir. 2009), the plaintiff, Kirsten Majeski, had been employed by Metropolitan Life Insurance Company (“MetLife”), and had participated in MetLife’s Short Term Disability Plan (the “Plan”).
The case centers on the decision of MetLife, as plan administrator, to reject Majeski’s claim for short-term disability benefits, after determining that Majeski had failed to submit enough evidence to support her claim. The district court had likewise rejected Majeski’s claim for the benefits and had granted summary judgment against her. (more…)
Category: 7th |
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Adam V. Russo | December 21, 2009
– On December 9, 2009, the United States Court of Appeals, Tenth Circuit, affirmed the federal government’s position that private insurance companies are “plans” and therefore subject to federal jurisdiction. (US vs. Frost)
Although other federal courts have held that contracts issued by insurance companies may be subject to federal jurisdiction under Title 18 Section 1347, US vs. Frost is the first case an insurance company itself has been held to be a “plan,” because, as the government claimed in this case, all insurance companies are “plans.” (more…)
Category: 10th, ERISA |
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Adam V. Russo | December 8, 2009
Davis v. AK Steel Corp., 2009 WL 3853608 (W.D. Pa. 2009)
The trial court in this case found that an employer’s SPD hand-delivery process satisfied DOL regulations, which require that the process be reasonably calculated to ensure that recipients receive SPDs and likely to result in full distribution. The employer had denied an employee’s claim for LTD benefits on the grounds that the employee failed to apply within the plan’s required timeframe. The employee sued claiming, among other things, that he never received the plan’s SPD that would have informed him of the application deadline. (more…)
Category: 3rd, ERISA, Plan Language |
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Adam V. Russo | December 8, 2009
An employee’s spouse sued the insurer of her cancer insurance policy in state court after it refused to pay for medical treatment she had received. The insurer removed the case to federal court, arguing that her claim was preempted by ERISA. The spouse argued that the case belonged in state court because the policy fit within the regulatory safe harbor that excepts from ERISA certain voluntary insurance arrangements. At issue was whether the policy, which was offered through a cafeteria plan, fell outside the voluntary plan safe harbor because the employer had endorsed it. (more…)
Category: 11th, ERISA, Preemption |
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Adam V. Russo | November 18, 2009
The law in many states provides that reimbursement to a plan from tort settlements or judgments will not be allowed unless the plan participant is “made whole.” Certainly, the plan participant is not made whole if the settlement or judgment is less than the amount of benefits paid. But even if the settlement or judgment id greater than the amount of benefits paid by the plan, the plan participant may not be made whole by it. Sometimes, it’s hard to draw a clear line to determine when a plan participant is or is not made whole. (more…)
Category: 6th, Made Whole Rule |
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Adam V. Russo | November 18, 2009
When it is clear that the tort settlement proceeds are held in a separate account and the plan clearly provides for 100-percent reimbursement, the fact that the plan beneficiary is a minor child will not preclude the plan’s entitlement to reimbursement. The case is Iowa Health System, Inc. v. Graham, 2009 WL 2222780 (C.D. Ill., July 23, 2009). (more…)
Category: 7th, Minor's Compromise |
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Adam V. Russo | November 18, 2009
Well drafted subrogation provisions will state that any allocation of tort settlement or judgments to reimburse non-medical losses – such as earnings lost – will not be binding on the plan. If that is stated, settlements or judgments won’t preclude the plan participant’s obligation to reimburse the plan. However, that’s not the necessarily the case when Medicare seeks to be reimbursed for the medical benefits that it paid. Indeed, contrary to the usual approach taken by privately sponsored health plans, the Medicare Secondary Payer (MSP) law on which Medicare’s right to reimbursement is based does not contain such a provision. (more…)
Category: 11th, Medicare |
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