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MyHealthGuide Source: Meredith Z. Maresca, BNA’s Pension & Benefits Daily, 1/27/2010, www.bna.com

In a decision addressing identification of the proper defendant in a benefit claim action brought pursuant to the ERISA’s civil enforcement provision, the U.S. District Court for the Southern District of Ohio held that the health plan’s TPA potentially could be liable for the alleged wrongful denial of benefits to cover a beneficiary’s bone cancer treatment. Read more

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 affect pre-emption analysis. In other words, a self-insured plan is still a self-insured plan, despite the existence of excess loss coverage. Read more

I received this from Dave Reynolds at Capitol.

Self Funding Article

January 22, 2010 (PLANSPONSOR.com) – A federal court has refused to dismiss a claim by a Jersey Construction employee that he was fired for pursuing health benefits for his wife’s chemotherapy.

The U.S. District Court for the District of New Jersey said it found that Christian Pailleret stated sufficient facts to support a prima facie case under § 510 of the Employee Retirement Income Security Act (ERISA). The court said Pailleret had no “smoking gun” evidence of intent, but the fact that almost immediately after he submitted medical claims of tens of thousands of dollars, he was assigned low-level and “degrading” tasks and shortly after that was terminated without notice or explanation was sufficient to show a plausible claim and “to thus unlock the doors of discovery.” Read more

Scaled-back bill seen as effort’s best chance

Jerry Geisel

WASHINGTON—Republican Scott Brown’s victory last week in the election to represent Massachusetts in the U.S. Senate has halted Democrats’ drive to pass sweeping health insurance reform.

The state senator came from behind in polls to win the U.S. Senate seat that Sen. Edward Kennedy held for 47 years until the Democrat’s death last August. Read more

By Andrea Davis

January 25, 2010

The U.S. Supreme Court heard arguments last week in a case that could have far-reaching implications for pension plan administrators and the way in which they interpret the terms of their plans.

“The justices were asking a lot of questions based on the particular facts of the case as opposed to the broader policy implications that this issue presents for all employers,” says Amy Covert, a partner in the labor and employment law department of Proskauer, who attended the session. Read more

This is a huge win for the subrogation industry.

The court held that Sereboff, rather than Knudson, controlled in this case. Like in Sereboff, the Plan targeted specific funds for recovery , Cusson’s LTD payments, and identified the specific portion to which Liberty is entitled— the amount of the overpayment while Cusson was receiving benefits under the LTD Plan. Read more

The Supreme Court has agreed to decide whether the attorney’s fees provision in the Employee Retirement Income Security Act (ERISA) permits courts to award such fees to prevailing parties only. In Hardt v. Reliance Standard Life Ins. Co. (No. 09-448), the Fourth Circuit, in an unpublished opinion, held that an employee who filed a claim in district court alleging that her denial of long-term disability benefits was unlawful was not entitled to an award of attorney’s fees. The lower court had agreed with the claimant and remanded the matter back to the insurance underwriter for reconsideration, which eventually granted her the benefits sought. Read more

Washington, D.C. — On January 18, 2010, The ERISA Industry Committee (ERIC), the Washington, D.C.-based trade association representing America’s major employers, sent a letter to the Administration and key Members of Congress urging that health reform support employer-based health care and expressing concerns over its future viability if certain provisions of the health care reform bills are enacted.

“The employer-based system in this country rests on the foundations of national uniformity, affordability, voluntariness, and the ability to spread risk across the entire employee population. These principals must be maintained in order for the employer-based system to continue to provide 170 million Americans with efficient, effective, and high quality health care,” said ERIC President Mark Ugoretz. Read more

For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform.

Wisconsin. The state is anticipating cutting more than $600 million from its Medicaid program. The areas targeted for cuts include delaying payments into the budget next year, increasing generic drug usage, reducing rural hospital reimbursement payments, and rebidding contracts for state health care programs. Even with those reductions, high demand from the poor for health insurance benefits could result in up to a $150 million shortfall. For more information, visit http://dhs.wisconsin.gov/MEDICAID/.

For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform.

Washington. Recent budget cuts have forced the state’s low-cost health insurance program, Washington’s Basic Health plan, to take no new customers, while the recession has increased demand for the plan. Approximately 78,834 people are enrolled in the plan, while 78,419 people are on the plan’s waiting list. For more information, visit http://www.basichealth.hca.wa.gov/.

For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform.

Tennessee. The state has cut off enrollment for two health insurance programs for low-income people: the CoverKids program, which is the state’s CHIP, and CoverTN, an insurance program designed for the self-employed and working poor. State officials say that with a projected $1.5 billion shortfall in the state’s $29 billion budget, there is no extra money to go around. For more information, visit http://www.covertn.gov/.

For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform.

North Carolina. The federal government is giving the state a $1.5 million grant to provide monthly subsidies to people to aid participation in the state’s high-risk insurance pool. The state’s high-risk pool provides health care coverage for those who cannot find affordable insurance in the private market. For more information, visit http://nchirp.org/.

For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform.

Montana. The state’s Healthy Montana Kids program has faced a large backlog of applications. The program, approved by voter initiative in 2008, expands Medicaid and CHIP, with the goal of covering an additional 29,000 children in low- and moderate-income families in Montana. More than 2,300 families have applied for the program for the first time since September, and only about 740 children have been added. Officials blame the backlog on a computer program. For more information, visit http://hmk.mt.gov/.

For the last few years, states have been leading the way toward more comprehensive health care coverage to ensure that more people have or can obtain health insurance. Because of the potential impact of this ongoing activity on employer-provided health insurance benefits, Spencer’s Benefits Reports provides regular updates about state health care reform.

Massachusetts. Lawmakers are considering a bill that would require every full- and part-time college student in the state to have at least the basic level of health insurance required under the state’s 2006 health care reform law. Under the proposal, any public or private institution of higher learning that fails to insure its students would face fines of $1 per student for every day the student remains uninsured. For more information, visit http://www.mass.gov/dph/.