Archive for the ‘Summary Plan Description’ Category

By Chris Aguiar of The Phia Group, LLC

Can anyone disagree with the notion of affordable healthcare? No matter where you sit on the political spectrum, I would imagine it would be difficult to vote against such an idea. Over the past few months, we have witnessed contentious debate on the most effective means to provide affordable healthcare for all. One of the main points of contention on that debate, as is always the case when dealing with political matters, is cost. Read more

An Overview of the MHPAEA Regulation Requirements

By Jennifer M. McCormick, Esq. of The Phia Group, LLC

Joint issuance of the interim final mental health parity regulations by the DOL, DHHS, and Treasury offer guidance for employers in ensuring compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Read more

click  here to see today’s Webinar on Innovative Plan Language Techniques.

click here to download the PowerPoint slides.

Please contact Bethany Hoffman with any questions or comments at 781-535-5608 or by email bhoffman@phiagroup.com

Due to technical difficulties with GoTo Webinar we will be rescheduling today’s webinar on “Innovative Plan Language Techniques” to next Thursday, December 17th at 12 PM EST.

We apologize for any inconvenience this may cause you.

Plan’s subrogation and reimbursement language may actually thwart their ability to recover from tort settlement proceeds benefits they paid. It is important for plan language to ensure that its recovery claim is limited to settlement proceeds. In one such case, a health plan did not identify a particular fund from which the reimbursement should be paid and it failed to say that the recovery was limited to third-party settlement proceeds. Because of the imprecise drafting, the court could assume the plan was trying to recover from the plan participant’s general assets. That created the possibility that a member could receive a recovery from a third party that was less than the benefit paid by the plan but would still have to repay the plan in full. As a result, the court found it impossible to award the recovery. Read more

MyHealthGuide Source: Employer’s Guide to Self-insuring Health Benefits, Todd Leeuwenburgh, Editor, Thompson Publishing Group. Copyright 2009. 11/13/09, www.thompson.com

Cases:

• Salisbury v. Hartford Life and Accident Co., 2009 WL 3112411 (10th Cir., 9/30/09)

• Lutz v. Philips Electronics North America Corp., 2009 WL 3236029 (3rd Cir., Oct. 8, 2009)

In two separate cases, U.S. circuit courts buttressed a plan’s right to invoke a time limit on lawsuits over benefit denials, by refusing to accept plaintiff arguments that the plans confused them about the starting point of the time limits. Read more

Reporting to Medicare

The purpose of these reporting requirements is to enable the Centers for Medicare & Medicaid Services (CMS) to determine whether those covered by Medicare are also covered by other insurance that, by law, must pay primary to Medicare. Read more

In Administrative Committee of the Wal-Mart Stores, Inc. v. Gamboa, 479 F.3d 538 (8th Cir. 2007), an ERISA plan administrator brought suit seeking equitable reimbursement from a plan participant who had received a settlement from a tortfeasor. Although the reimbursement provision was contained in an SPD for a health plan, the employer had no formal written health plan. Reversing summary judgment for the participant, the Eighth Circuit held that the plan administrator reasonably construed the SPD to be on the plan document for purposes of a group health plan in the absence of any formal plan and that the reimbursement provision in the SPD was therefore enforceable. Read more

Starting April 1, group health plans must offer a special enrollment right and coordinate coverage for individuals who are either entering or exiting state health coverage programs. Under the law reauthorizing the State Children’s Health Insurance program (SCHIP), plans and insurers must allow an employee or dependent to enroll under the terms of the plan if: (1) he or she loses SCHIP (or Medicaid) eligibility and asks to be covered under the group plan within 60 days; or (2) he or she becomes eligible for premium assistance under SCHIP or Medicaid to buy group health coverage and asks to be covered within 60 days of that eligibility determination. Plans must meet minimum creditable standards to enable individuals to receive premium support. Read more

Sharon Mondry worked for American Family and sought payment for speech therapy for her son from her self-funded health plan sponsored by American Family and administrated by the CIGNA the TPA. CIGNA denied payment fro Zev Mondry’s speech therapy on the basis that it was educational training and not restorative pursuant to the terms of the Plan Document. After months of trying, Mondry finally obtained all the relevant Plan documents and eventually got CIGNA to reverse its denial and pay the claims. Mondry filed suit alleging that American Family and CIGNA had violated a statutory obligation to produce plan documents and breached their fiduciary duties by misrepresenting the terms of the Plan. Read more

From the Clear Direction Blog www.cleardirectionblog.com
Posted: 18 Mar 2009

A recurring issue for health plan subrogators is what language is sufficient to override the make whole rule. On the one hand, Circuits like the Fifth Circuit have held that no particular language is required to overcome the make whole rule. In the Fifth Circuit (and others like it), plan language simply providing for 100% recovery is sufficient. Read more

Many involved in the administration of ERISA Plans do not realize that some state insurance law is preempted even when a fully insured ERISA Plan is involved.

In Spellman  v. United Parcel Service, 540 F. Supp.2d 237 (D.C. Maine 2008), the Court addressed an issue of enforcing Maine’s  workers’ compensation statutes with regards to health plans under ERISA. Read more

Shelby County Healthcare Corp, d/b/a Regional Medical Center v. The Majestic Star Casino, LLC group Health Benefit Plan, 2008 WL 782642 (WD Tenn.) has demonstrated that even though the SPD gives the Plan the final decision to accept or deny medical claims, discretion does not apply to the Plan’s TPA.Damon Weatherspoon, a plan participant of the Majestic Star Casino LLC Group Health Benefit Plan was involved in a single vehicle accident and sustained over $400,000 in medical expenses at the Regional Medical Center.  Reports indicated that Weatherspoon had violated Mississippi law by driving under the influence, driving without a valid Mississippi driver’s license and driving without insurance. Read more

By Ron E. Peck, Esq.

If you have read the postings below (addressing the ongoing Supreme Court case of MetLife v. Glenn) you will note that the matter of what standard of review a Court applies when reviewing an administrator’s decision, is a major topic of conversation.  The issue literally dominates how much power administrators will have to interpret the terms of their plan documents.  In general, having discretion to interpret terms, and enjoying the Court deference that comes with it, is extremely important to administrators.  Discretion and deference, however, do not always guarantee Court acceptance of an administrator’s interpretation of plan terms. Read more

By Ron E. Peck, Esq.

On April 30th, we posted a discussion of the ongoing Supreme Court case, MetLife (Metropolitan Life Insurance Company), et al. v. Wanda Glenn, 128 S.Ct. 1117.  To review, in that case the Court is questioning whether a deferential standard of review – the standard ordinarily applied by Courts reviewing ERISA administrator decisions when the Plan reserves discretionary authority – should be replaced by a more searching analysis when the administrator financially benefits from denials. Read more