You already know that evidence of a “conflict of interest” can change the standard of review the court applies in ERISA claims.
But proper structuring of multi-employer benefit plans can avoid an inherent conflict of interest.
Here’s the case of Foltz v. Barnhart Crane and Rigging, Inc., __ Fed. Appx. __ (6th Cir.
You know there has been a court trend toward narrowing ERISA preemption.
But…that trend was brushed back today by the U.S. Supreme Court.
Here’s today’s case: Gobeille v. Liberty Mutual Insurance Com., __ U.S. __ (March 1, 2016) (State regulations that impinge upon ERISA’s core functions, like reporting, are preempted by ERISA) [PDF].
FACTS
You know that procedural irregularities in an appeal denial of a claim for ERISA-governed benefits can change the standard of review from arbitrary and capricious to de novo review.
But not all the time. The claimant should also “provide meaningful new evidence or raise significant new issues on administrative appeal.”
Here’s the case of
You already know that claimants with a denied claim must submit an appeal and exhaust administrative remedies before filing suit.
But are phone calls sufficient to trigger the appeal process?
And, can a claimant trump the exhaustion requirement by alleging the denial was in “bad faith” and, therefore was a “special circumstance?”
Here’s the case
This just in….
A big debate was resolved today by the United States Supreme Court:
Can an ERISA plan sue to recover medical expenses paid on the participant’s behalf after the settlement funds have dissipated? Generally…NO. The rule applies to “equitable liens by agreement,” too.
Here’s the case of Robert Montanile v. Board of
Insurers are getting hit with more class actions regarding the denial of medical treatments, like behavioral therapy treatments for autism spectrum disorders. These can be expensive: In May 2015 ConAgra Foods Inc. and Blue Cross Blue Shield were sued in a proposed class action in California, accused of denying behavioral therapy treatments for autism
What happens when the ERISA long term disability benefit plan does not define “full-time”?
The Department of Labor says “full-time” is defined by the employer. http://webapps.dol.gov/elaws/faq/esa/flsa/014.htm
The Affordable Care Act defines “full-time” as working 30 hours a week. https://www.healthcare.gov/glossary/full-time-employee/
When interpreting undefined ERISA plan provisions, courts apply general principles of contract law.
So, applying general
The Employee Benefits Security Administration (EBSA) announced plans to publish, on November 18, 2015, new proposed claims procedures for handling ERISA-governed disability benefits. The pdf can be accessed HERE.
Comments are encouraged and must be submitted within 60 days of publication of the proposed new claims procedures.
The proposed new claims procedures apparently
You know that patients typically assign rights under a health insurance plan to the provider of medical services. This is accomplished by signing an assignment form upon intake/admission. Then, the healthcare provider sends the claim directly to, and receives reimbursement directly from, the patient’s health insurance company for services rendered to the patient.
But what
You already know that in March 2015, the 6th Circuit issued an en banc decision rejecting disgorgement of profits claims. Rochow v. Life Ins. Co. of N. Am., 780 F.3d 364, 372 (6th Cir. 2015)(en banc) (rejecting $3.8 million disgorgement claim against Life Insurance Company of North America as “an impermissible duplicative