cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
As illustrated here, ERISA did not preempt the Washington Mental Health Parity Act.
Even though it correctly applied an insured ERISA plan’s coverage restrictions on neurodevelopmental therapy for children over six years old, the administrator’s refusal to pay a 10-year-old dependent’s mental health treatment violated a state law that bound insurers and HMOs. (more…)
Category: ERISA, Health Care Legislation, Mental Health Parity, PPACA, Preemption, Supreme Court, Washington |
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cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
A claims administrator lost an attempt to dismiss negligence and breach of contract charges relating to its failure to process and pay a large claim before the final day of a stop-loss policy’s run-out period.
The self-insured Hebrew Home health plan sued administrator CoreSource and stop-loss insurer Sun Life for negligence and breach of contract under state law, alleging that the administrator dragged its feet paying the claim and ended up missing a March 31 deadline that would have enabled the plan to collect $180,000 in stop-loss reimbursement. (more…)
Category: 4th, ERISA, Maryland, Preemption, Stop Loss |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The attempted treatment of stop-loss coverage as “health insurance” subject to state insurance law has been a thorn in the sides of self-funded plans seeking to maintain ERISA preemption of state insurance laws.
In Goyen v. Vail Corp., 2011 WL 4479091 (D. Colo., Sept. 26, 2011), a federal district court rejected a plaintiff’s argument that a plan stopped being self-funded and lost ERISA preemption, all because it had taken out a stop-loss policy. (more…)
Category: 3rd, 6th, ERISA, Preemption, Self-Funding, Stop Loss |
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cmonfils | October 13, 2011
www.businessinsurance.com
Few other business cases placed on the docket
Oct. 02, 2011 Mark A. Hofmann
WASHINGTON—The U.S. Supreme Court opens its October term Monday with a docket unusually light on risk management- and insurance-related cases.
In fact, the docket contains relatively few business-related cases, as Robin Conrad, executive vp of the Washington-based National Chamber Litigation Center Inc., which handles litigation for the U.S. Chamber of Commerce, noted in a pre-term briefing late last month. As of late September, only 41% of the high court’s docket consisted of business-related cases, compared with 45% at the same time last year. (more…)
Category: Preemption, Supreme Court |
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cmonfils | August 2, 2011
www.myhealthguide.com
MyHealthGuide Source: The Self-Insurance Institute of America, Inc. (SIIA), 7/28/2011, www.SIIA.org
The Self-Insurance Institute of America, Inc. (SIIA) welcomed the victory by a Vermont-licensed risk retention group (RRG) that appealed Nevadas attempt to bar its operation despite federal preemption under the Liability Risk Retention Act (LRRA). SIIA had submitted an amicus brief in support of the RRG. (more…)
Category: Nevada, Preemption |
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cmonfils | May 9, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 5/4/2011, www.thompson.com
Case: Hansen v. Harper Excavating, 2011 WL 1379821 (10th Cir., April 13, 2011)
Fine distinctions about an employee’s status as a non-ERISA beneficiary allowed his state-law case — even though he had already prevailed on an ERISA complaint based on closely related facts — to survive, a U.S. appeals court has ruled in the above case. (more…)
Category: 10th, ERISA, Preemption |
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cmonfils | May 3, 2011
Coordination of Benefits April 2011 | Vol. 19, No. 2
ERISA does not necessarily preempt an employee’s lawsuit against his group health plan’s subrogation vendor for alleged improper disclosures of his medical records, a federal district court recently ruled. Although the lawsuit arguably “related to” an ERISA plan, it was not “completely” preempted so as to take it out of state court, a federal district court ruled in Quintana v. Lightner, 2011 WL 976773 (N.D. Texas, March 21, 2011). (more…)
Category: HIPAA, Preemption, Summary Plan Description |
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cmonfils | February 2, 2011
www.healthplanlaw.com
January 26, 2011 •
The second prong of the Pascack test is also satisfied. Plaintiff identifies no other “independent legal duty” that would support its claims. Plaintiff’s argument that this is a “rate of payment” case is of no avail. 6 Plaintiff admits that it has no contractual relationship with any Defendants. At the same time, it argues that its right to payment is dependent upon assignments of benefits. The amount of payment (i.e., the “rate”) at issue would necessarily implicate the rates in the ERISA plans under which Plaintiff claims it has received assignments. (more…)
Category: ERISA, Federal Circuits, Litigation, Preemption |
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Adam V. Russo | 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” and “common fund” rules. States have an interest in: (1) keeping the cost of auto liability insurance low; (2) ensuring that wrongdoers pay full damages; and (3) making sure attorneys are paid for representing clients. These are at odds with the federal government’s goal of keeping the cost of health coverage reasonable. It remains to be seen if the federal government will try to resolve this through preemption of state laws beyond self-funded ERISA plans.
Category: Attorneys' Fees, ERISA, Made Whole Rule, Preemption, Subrogation |
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Adam V. Russo | 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 time is needed to develop regulations dealing with the vast scope and complexity of those problems, and because of the need to phase in increased costs that reform will cause in its early years. That means we really won’t know whether or not the law will achieve either goal, or even if it will survive the current complex political situation. (more…)
Category: ERISA, Health Care Legislation, Made Whole Rule, Preemption, Subrogation |
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Adam V. Russo | 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 page 11 of this Newsletter, the objectives of ERISA sometimes conflict with the objectives of state laws. (more…)
Category: ERISA, New Jersey, Preemption, Subrogation, Supreme Court, Welfare Benefit Plans |
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Adam V. Russo | 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 the plaintiff. The case is Ingenix v. Ham, 2010 WL 1780012 (Fla. App., May 5, 2010). (more…)
Category: Attorneys' Fees, ERISA, Florida, Preemption, Subrogation |
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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… (more…)
Category: 9th, Preemption, Summary Plan Description |
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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 filed by insurers and nonprofit health care corporations doing business in the state. Under OFIS’s authority to regulate insurance, it promulgated rules, Michigan Administrative Code Rules 500.2201-500.2202 and 550.111-550.112, prohibiting insurers from issuing, delivering, or advertising insurance contracts or policies that contain “discretionary clauses” and providing that any such clause is void and of no effect. The rules took effect June 1, 2007. Given that employee benefit plans established or maintained under ERISA commonly contain discretionary clauses, the rules would prohibit any entity covered by them from “issuing, advertising, or delivering to any person in the State of Michigan, including an employee benefit plan subject to ERISA, an under-written policy or certificate that includes a discretionary clause.” (more…)
Category: 6th, ERISA, Flexible Spending Accounts, Michigan, Preemption, Summary Plan Description |
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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 former spouse was entitled to receive payment from the plan because the divorce decree could not overcome the express terms of a plan document. (more…)
Category: ERISA, Preemption, Summary Plan Description, Supreme Court |
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