cmonfils | May 3, 2012
When Sharon Smith chose an out-of-network specialist to perform a complicated jaw surgery on her teenage son last May, she knew it would cost her more. But she was not expecting $15,000.
Consumers have long complained about the cost of going outside their health plan’s network, but Smith encountered a new twist: A growing number of insurers have changed the way they calculate reimbursements to shift more of the expense to patients.
http://www.usatoday.com/money/industries/health/story/2012-01-27/medical-bills-out-of-network-surprises/53013494/1
Category: Health Insurance, Medicare, Reimbursement |
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cmonfils | April 24, 2012
FKI and ACS rely on Bombardier for the proposition that a benefit plan can recover from a third party that is holding the funds “on behalf of a plan-participant client who is a traditional ERISA party.” Id. at 353. However, that is not the case here, because unlike the attorney in Bombardier, who was found to be subject to the client’s control, the Trust in this case cannot be controlled by Larry Griffin.
Category: 5th, Reimbursement |
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cmonfils | March 30, 2012
www.subrogation.org
Connecticut Senate Bill 422: Currently in the Committee on Judiciary, Senate Bill 422 is an attempt to revise the methodology used for calculating an employer’s reimbursement for workers’ compensation benefits paid out when the injured employee recovers damages in an action against a third-party tortfeasor. (more…)
Category: Connecticut, Legal, Reimbursement, Workers' Compensation |
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cmonfils | March 26, 2012
Under PPACA, group health plans are prohibited from imposing annual dollar limits on “essential health benefits” starting in 2014 (and can only impose limits exceeding certain specified amounts for plan years beginning before then).
Category: PPACA, Reimbursement |
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cmonfils | March 23, 2012
Most ERISA welfare benefit plans have provisions that allow the plan to recoup amounts of medical expenses it paid to participants or beneficiaries for injuries or illnesses caused by third parties (such as those sustained in automobile accidents), where the participant obtains a recovery from the third party. Often, an ERISA plan member will argue that such reimbursement is not required unless the member was “made whole” by the third-party recovery, that is, where the recovery fully compensates the member for his or her injuries, after all deductions are made (including for attorneys’ fees). Plans often draft around such arguments by requiring reimbursement regardless of whether the plan member was made whole.
Category: ERISA, Made Whole Rule, Reimbursement |
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cmonfils | March 14, 2012
I conclude that Rule 9(b) does not apply to the negligent misrepresentation claim before me. The crux of the claim is that Beverage failed to use reasonable care or competence in obtaining and communicating information concerning Hood’s eligibility. This rings not of fraud but negligence. See, e.g., Bloskas v. Murray, 646 P.2d 907, 914 (Colo.
Category: ERISA, Reimbursement |
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cmonfils | March 2, 2012
The Self-Insurer – February 2012 Issue, Volume 40
From The Bench by Steven T. Polino
By now we all know that Plan fiduciaries can obtain reimbursement of benefits the Plan pays for injury suffered by a Plan beneficiary as result of negligence, misconduct, or other actions of a third party. The plan need only satisfy two requirements. The Plan’s Subrogation – Reimbursement language must identify a particular fund, distinct from the beneficiary’s personal assets, from which the beneficiary obtains recovery and a particular share of that fund in the possession or under the control of the beneficiary. Sereboff v. Mid – Atlantic Medical Services, Inc., 547 U.S. 356, 363 – 64 (S.Ct. 2006). (more…)
Category: Fiduciary, Reimbursement, Self-Funding, Subrogation |
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cmonfils | February 19, 2012
Coordination Of Benefits January 2012 Vol. 20 No. 1
Virtually all employer-sponsored health plans in effect today provide that the benefits they pay are subject to reimbursement from both fault and no-fault auto liability insurance proceeds. Indeed, in just about every reported case we have seen, federal courts have ruled in favor of self-funded ERISA health plans allowing recovery of the benefits they paid by from no-fault auto liability policies. A very interesting decision by a U.S. District Court in Michigan tells us that the result is not the same if the employer’s ERISA health plan is insured. The case is Horrell v. CEC Entertainment, Inc., 2011 WL 4954031 (W.D. Mich., Oct. 19, 2011). (more…)
Category: ERISA, Michigan, Reimbursement, Self-Funding, Subrogation |
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cmonfils | February 19, 2012
Coordination Of Benefits January 2012 Vol. 20 No. 1
Most employer-sponsored health plans reserve the right to recover benefits payments they made from both fault and no-fault auto liability insurance proceeds. But outcomes can be very different if the employer’s ERISA health plan is insured (that is, not self-funded). Michigan’s No-fault Insurance Act provides that auto liability insurance will be secondary to other health insurance, in order reduce the cost of no-fault insurance. State laws govern insured health plans. ERISA plan provisions in a health insurance policy to the contrary are not enforceable, so ERISA preemption did not apply. If the plan had been self-funded, ERISA would have preempted the Michigan law. Federal courts almost unanimously rule in favor of self-funded ERISA health plans seeking recovery of benefits paid from auto liability policies. (more…)
Category: ERISA, Health Insurance, Michigan, Reimbursement |
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cmonfils | February 14, 2012
www.subrogation.org
Arizona House Bill 2547. The Arizona House recently introduced a bill barring subrogation rights and a right to reimbursement for auto, health and property carriers! The bill was introduced on January 12, 2012. (more…)
Category: Arizona, Reimbursement, Subrogation |
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cmonfils | February 14, 2012
www.myhealthguide.com
MyHealthGuide Source: Employee Benefit Research Institute (EBRI), 1/2012, EBRI New Release and EBRI Full Text Brief with Charts (more…)
Category: News, Reimbursement |
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cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
In a surprising decision, the 3rd U.S. Circuit Court of Appeals used the concept of “appropriate equitable relief” to restrict an employer-sponsored health plan’s recovery from a third-party settlement. Full reimbursement of what the plan paid out would have been “inappropriate and inequitable,” even though the plan had asserted recovery rights over any monies collected from a third party. Full recovery would have been unfair because: (1) the plan participant’s recovery ended up being less than what the plan paid after attorney’s fees were deducted; and (2) the plan never intervened in the third-party recovery. The outcome diverges from many recent cases, which upheld plans’ claims on total proceeds, regardless of whether the plan participant was “made whole” or had money to pay attorney’s fees. (more…)
Category: 3rd, Common Fund, ERISA, Pennsylvania, Reimbursement, Subrogation, Third Party Agreements |
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cmonfils | January 8, 2012
The District Court of Montana dismissed a putative class action against insurer John Alden last Thursday citing the Policy’s 3-year statute of limitations. The plaintiff brought suit against the insurer alleging it had used a defective database that produced inaccurate calculations for reimbursement of health care charges. Plaintiff was insured under an ERISA-governed employee welfare benefit plan that included medical coverage.
Category: ERISA, Reimbursement |
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cmonfils | December 29, 2011
San Francisco Mayor Edwin Lee in November signed legislation that imposes new rules on the use of health reimbursement arrangements to satisfy the city’s health care spending law. Among other things, employees will have more time to use their account balances and have a new right to tap account balances after they terminate employment, while employers have new requirements to provide to employees a summary of contributions and reimbursement amounts. The City and Country of San Francisco Labor Standards Enforcement department has published the full law, highlighting the most recent changes, as well as sample contribution and separation of employment forms.
Category: California, Reimbursement |
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cmonfils | December 21, 2011
Self-Insurer December 2011 Issue, Volume 38
By Michael Friedman and John Eggertsen
The subtleties of subrogation Analysis, or when drafting plan Language it is not so simple to say what you mean in a way a court will understand it.
For those who stick with this discussion of the Court’s assessment of the subrogation and reimbursement provisions in Two ERISA Plans, it will become abundantly clear that courts will review such provisions with the proverbial fine tooth comb, and that careful and explicit drafting is required in order for a plan administrator to enforce a plan’s rights. (more…)
Category: 9th, ERISA, HIPAA, Reimbursement, Subrogation |
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