bhoffman | August 25, 2010
Coordination of Benefits Handbook
The government has yet to sort out the conflicting interests involved in subrogation/reimbursement dispute. Because there will be no reform body directly creating subrogation/reimbursement rules, the matter remains one of balancing various laws. For instance, laws in many states limit plans’ ability to recover health expenses based on the “make-whole,” “collateral source” [...]
bhoffman | August 25, 2010
By Jack B. Helitzer, Esq., Coordination of Benefits Handbook
The federal health care reform law attempted to address two major problems with health coverage in the United States; (1) expansion of coverage to the uninsured; and (2) reducing overall health care costs. Most reform provisions won’t take effect for at least a few years. That’s because [...]
bhoffman | August 25, 2010
Coordination of Benefits Handbook
We are familiar with cases where ERISA and state laws conflict. As we know, self-insured health plans that are subject to ERISA may avoid the application of state laws because of ERISA preemption. As we have seen in our analysis of the case Bash v. State Farm Mutual Automobile Insurance Co. on [...]
bhoffman | August 25, 2010
Coordination of Benefits Handbook
In a case that does not involve a health plan subject to ERISA, a Florida appellate court ruled that a health plan’s reimbursement from the proceeds of a settlement of a medical malpractice case was limited to the amount paid by the plan less its pro-rata share of attorney’s fees incurred by [...]
Adam V. Russo | July 9, 2010
Like Ross, the Ninth Circuit issued a similar ruling in Standard Insurance Co. v. Morrison. Montana requires its commissioner of insurance to disapprove any [insurance] form…if the form…contains…any inconsistent, ambiguous, or misleading clauses or exceptions and conditions which deceptively affect the risk purported to be assumed in the general coverage of the contract…
Adam V. Russo | July 9, 2010
Defendant-appellee Ken Ross is the commissioner of the Michigan Office of Financial and Insurance Services (OFIS). OFIS is responsible for licensing, examining, and supervising insurers and nonprofit health care corporations doing business in Michigan. To this end, OFIS’s authority includes the power to disapprove insurance policy forms and documents associated with such forms that are [...]
Adam V. Russo | July 9, 2010
This unanimous decision resolved a split in the lower courts over a fact pattern regularly faced by administrators of ERISA plans when an employee and spouse are divorced, but the employee dies before changing the beneficiary designation for benefits. In Kennedy, the Supreme Court held that, notwithstanding the contrary terms of a divorce decree, the [...]
Adam V. Russo | April 27, 2010
In Hall v. Newmarket Corp, Aetna Life Insurance Co., et al. ___F.2d___(D.C. MS. 2009), Theresa Hall was covered through her employer, Newmarket, under a self funded arrangement that was administered by Aetna. When her plant closed down she continued coverage through Aetna and paid premiums to Aetna from 2001 to 2004, when she switched over [...]
Adam V. Russo | April 20, 2010
Plaintiffs argue that Medical Mutual, in its processing of insurance claims, violated the federal RICO statute. Specifically, Plaintiffs allege that Medical Mutual “acted to delay, diminish and deny payment of . . . lawful claims of patient-insureds as submitted by out-of-network health providers . . . through a scheme or artifice, utilizing the U.S. Mail [...]
Adam V. Russo | January 29, 2010
The Boeing Company v. Thurmon, No. 4:09-cv-1456, in the United States District Court for the Eastern District of Missouri, December 7, 2009. This is a subrogation case, significant for its fresh and express reiteration of the bedrock proposition that purchase of stop loss insurance by the sponsor of a self-insured employee benefit plan does not [...]
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 [...]
Adam V. Russo | November 18, 2009
W.E. Aubuchon Co. v. BeneFirst, LLC, 2009 WL 3272491 (D. Mass. 2009
The employer in this case sued the former TPA of its two self-insured medical plans for claims processing errors that allegedly created millions of dollars in additional costs for the plans. Asking the court to enter judgment in its favor, the TPA argued that [...]
Adam V. Russo | November 18, 2009
By Stanley D. Baum – Erisalawyerblog.com
In Hitachi High Technologies America, Inc. v. Bowler, SJC-10386 (Supreme Judicial Court of Massachusetts 2009), the Court faced the question of whether ERISA preempts a State law action brought by a retirement plan fiduciary to recover money mistakenly paid to a plan participant. In this case, the plaintiff, Hitachi High [...]
Adam V. Russo | June 24, 2009
by John H. Eggertsen, Esq. and Michael Friedman, Esq. of SIIA, www.siia.org
I. District of Columbia’s Efforts to Regulate PBMs Preempted by ERISA
In their efforts to combat the ongoing initiatives on the part of several states to regulate the business activities of pharmacy benefit managers (“PBMs”), the PBMs recently won a skirmish. In Pharmaceutical Care Management [...]
Adam V. Russo | June 10, 2009
In American Council of Life Insurers v. Ross, case, 2009 U.S. App. LEXIS 5748,F.3d (6th Cir. 2009), the Sixth Circuit held that a Michigan law prohibiting insurers from including discretionary language in insurance policies fell within the scope of ERISA preemption “savings clause” and was therefore enforceable. The court relied on the Supreme Court’s Miller [...]
