cmonfils | January 15, 2012
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 1/12/2012, www.Thompson.com
Case: Pacific Shores Hosp. v. United Behavioral Health, 2011 WL 6402435 (C.D. Calif., Dec. 19, 2011)
A benefit administrator’s adverse benefit determination was imperfect but sufficient to comply with claims procedure rules, the U.S. District Court for the Central California district concluded in the above case. Discrepancies by reviewing physicians and adjustments made in discharge criteria were not enough to support allegations of claims-procedure violations and overturn the denial, it held. (more…)
Category: California, Claims Procedures, Plan Language |
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cmonfils | November 16, 2011
In our prior blog, we explained that under principles of triage, employers may need to focus on the current annual enrollment and wait to take care of the Summary of Benefits and Coverage (“SBC”). Although the SBC does not need immediate attention, we caution employers not to wait too long or take the SBC responsibilities too lightly. The penalties for failing to satisfy the SBC requirements are severe. This blog will explain what those penalties are and the steps to take to avoid them. In a subsequent blog, we will provide more details regarding specific content requirements and the different groups of people who must be given the SBC.
Category: ERISA, Health Care Legislation, Plan Language, PPACA, Self-Funding, Summary Plan Description |
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cmonfils | November 4, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 6/24/2011, www.Thompson.com
Case: Spectrum Health v. Lehr, No. 298688, (Mich.App., 9/8/2011)
A beneficiary cannot pick definitions from various state or federal statutes and impose them on the plan where the plan left terms undefined, if the plan applies a common and ordinary meaning to those terms when asked to justify a claims denial. (more…)
Category: Health Insurance, Plan Language |
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cmonfils | October 26, 2011
So half the parties interpreting a possibly ambiguous plan term that is subject to discretionary review come out one way in reading the term, and the other two the other way. Who wins? Well, this is a trick question to some extent, because it doesn’t matter the numbers – all that matters is who gets the last say. This means, of course, that the side who wins that split is whichever one the appeals court agrees with.
Category: Plan Language |
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cmonfils | August 30, 2011
www.myhealthguide.com
MyHealthGuide Source: Rebecca Moore, PlanSponsor, 8/25/2011, PlanSponsor Article
Case: Baker v. Pennsylvania Economy League Inc. Retirement Income Plan, E.D. Pa., No. 2:10-cv-06738-AB, 8/23/11
Editor’s Note: While the subject of case is a pension plan, the court’s ruling against plan administrator and fiduciary breach has application for self-funded ERISA plans. Court rules that plaintiff./ claimant could continue with her claim against plan administrators’ actions constituted a fiduciary breach. (more…)
Category: ERISA, Pennsylvania, Plan Language, Self-Funding |
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cmonfils | June 7, 2011
www.orrick.com
The Supreme Court’s recent decision in CIGNA Corp. v. Amara, No. 09-804, 563 U.S. ____ (2011) has important implications for plan sponsors and those involved in benefit plan administration. In Amara, the Supreme Court held that ERISA does not grant the ability to a court to “reform” a plan to change plan terms to match those in a summary plan description (SPD), and that claims for benefits by plan participants under ERISA cannot be based on incorrect information in SPDs. The Court clearly held that the formal plan document, not the SPD or other informal benefits communications, controls the provision of benefits under the plan. If the Court had ended its analysis there, the decision would be an outright victory for plan sponsors. (more…)
Category: Plan Language, Summary Plan Description, Supreme Court |
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cmonfils | May 26, 2011
www.healthplanlaw.com Roy Harmon III May 17, 2011 ·
Why the Court embarks on this peculiar path is beyond me. It cannot even be explained by an eagerness to demonstrate — by blatant dictum, if necessary — that, by George, plan members misled by an SPD will be compensated. (more…)
Category: ERISA, Plan Language, Summary Plan Description, Supreme Court |
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cmonfils | May 16, 2011
www.healthplanlaw.com Roy Harmon III May 12, 2011
Defendants argue that the first amended complaint is deficient because, with the exception of Count Four, which is identified as a claim for benefits pursuant to §1132(a)(1)(B), plaintiff fails to specify the ERISA statutory provisions upon which her claims are based. This argument is not well taken. (more…)
Category: 6th, 7th, Plan Language |
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cmonfils | April 1, 2011
www.hr.cch.com
3/28/11
from Spencer’s Benefits Reports: A two-month stay at a residential treatment facility for cocaine addition did not qualify for plan coverage because an acute level of care was not needed after two days, the Sixth Circuit Court of Appeals ruled in upholding the plan’s denial of benefits (Meredith Solomon v. Medical Mutual of Ohio, No. 09-4152). (more…)
Category: Mental Health Parity, Ohio, Plan Language |
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cmonfils | March 1, 2011
Thompson Publishing January 2011 Volume. 19, No. 1
Based on recent court decisions, self-insured ERISA health plans will be entitled to reimbursement of the health benefits they paid from tort settlement proceeds if the plan’s language clearly requires such a result. In addition, when a plan delegates sole discretion to the plan administrator to interpret the plan language, it is well established that courts may not substitute their own judgment unless the plan administrator’s interpretation is deemed to be arbitrary and capricious. Also, it is clear that a plan’s right to reimbursement is limited to clearly traceable to the tort settlement proceeds. (more…)
Category: Plan Language, Reimbursement |
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cmonfils | January 12, 2011
www.healthplanlaw.com
January 7, 2011 • Roy Harmon III
ERISA provides federal courts with jurisdiction to review benefits determinations made by fiduciaries or plan administrators. 29 U.S.C. § 1132(a)(1)(B); see also Lopez ex rel. Gutierrez v. Premium Auto Acceptance Corp., 389 F.3d 504, 509 (5th Cir. 2004). A district court’s function when reviewing ERISA claims is like an appellate court’s.
“[The court] does not take evidence, but, rather, evaluates the reasonableness of an administrative determination in light of the record compiled before the plan fiduciary.” Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir.2002). Courts cannot consider additional evidence “resolve the merits of the coverage determination—i.e. whether coverage should have been afforded under the plan-unless the evidence is in the administrative record, relates to how the administrator has interpreted the plan in the past, or would assist the court in understanding medical terms and procedures.” Crosby v. La. Health Serv. & Indem. Co., — F.3d —, No. 10-30043, 2010 U.S. App. LEXIS 26323, *8, 2010 WL 5356498 (5th Cir. Dec. 29, 2010). A claimant is not permitted to explore, through discovery in an ERISA lawsuit, what information a plan administrator “should have considered” in making its benefits determination, as opposed to analyzing the information that the plan administrator “did consider” in making its decision. Griffin, 2005 U.S. Dist. LEXIS 18720, 2005 WL 4891214, at *2. (more…)
Category: 5th, Plan Language, Texas |
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Adam V. Russo | December 14, 2010
By Tom Lawrence, www.healthsubrogationblog.com
A recurring issue for health plan subrogators is whether a state law — or federal common law — common fund doctrine requires a health plan to reduce it’s subrogation amount by one-third. In Electric Energy, Inc. v. Lambert, in the United States District Court for the Western District of Tennessee, No. 10-2629-STA-tmp (December 2, 2010), the Court held that the Illinois common fund doctrine was preempted by ERISA and plan language rejecting the common fund doctrine was sufficient to preclude application of a federal common law common fund doctrine. (more…)
Category: 6th, Plan Language |
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Adam V. Russo | November 22, 2010
MyHealthGuide, www.myhealthguide.com
MyHealthGuide Source: Adam V. Russo, Esq., Co-founder, CEO of The Phia Group LLC, and contributing editor for Thompson Publishing Group’s the Employer’s Guide to Self-insuring Health Benefits, Todd Leeuwenburgh, Editor.
When visiting London, there are many fascinating sights to visit. You may choose to spend some time strolling around Piccadilly Circus, visiting some of the local pubs, or seeing historic Westminster Abbey or Big Ben. Regardless, one of the fastest and easiest ways to get from point A to point B is via the London Underground, or if you’re a local, the Tube. The Tube is London’s subway system, and if you’ve ever had the pleasure of using it, you’ll remember one thing above all else: “Mind the Gap!” In England, they want you to avoid the space between the boarding platform and the train. (more…)
Category: Plan Language, Summary Plan Description, Third Party Agreements |
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Adam V. Russo | October 6, 2010
Tomorrow I will be speaking at SPBA’s Fall 2010 Meeting in Phoenix, AZ.
Click here to see a sneak peak of my presentation “How to Avoid PPO Landmines”
Category: Plan Language, Provider Reimbursement, Third Party Agreements |
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Adam V. Russo | May 7, 2010
Yesterday, I presented on “Plan Compliance Issues” at Regional Care, Inc.’s annual forum, held at the Gering Civic Center in Gering, NE. With over 200 attendees, the forum was a great success.
Click here to see my entire PowerPoint presentation.
Category: Plan Language |
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