Cases and Commentary

MUSINGS ON DIVERSITY SENSITIVITY

MUSINGS ON DIVERSITY SENSITIVITYNo, not the HR kind! The jurisdictional kind. As in, will the game be played in State or Federal court? Will it be a home game or an away game? How is the spread affected by where we play? Get it?A recent case brought this subject to mind, City of Vista v. General Reinsurance, No.17-cv-2384, in the United States District Court for the Southern District of…

Article Yesterday Regarding Referenced-Based Pricing Litigation

Some of you will find this of…

MUSINGS ON MGU CONFLICTS OF INTEREST

  MUSINGS ON MGU CONFLICTS OF INTERESTConflicts of interest are all the rage these days.For our purposes, a working definition of a conflict is “a situation in which the concerns or aims of two different parties are incompatible;” another is: “a situation in which a person is in a position to derive personal benefit from actions or decisions made in their official capacity.”…

MUSINGS ON ERISA DENIAL LETTERS

There is a split of authority in the Courts of Appeal as to whether an ERISA denial letter that fails to comply with certain DOL regulations means that the claimant gets a free pass on the limitations period for filing suit set forth in the Plan document.Specifically, the First, Third and Sixth Circuits that have held just that. The Eleventh Circuit has held otherwise, as have the Ninth and Tent…

ADA Musings

A few years back, I received a spate of inquiries about whether an employee on ADA leave as a “reasonable accommodation” remained covered under the Plan. My answer is, and remained until today, “NO.”Then I got a new matter in today, where the Plan stated in a “Plan Sponsor Continuation Coverage” section: “Coverage will be continued for Eligible Covered Persons…. If the Covered Person qualifies…

There Is No Such Thing as a “Partially Self-Funded” Plan

In Brunnell v. Mid-America Associates, Inc., No. 16-cv-13466, (E.D. Mich. 2017), an ERISA benefits claim case, the Court rejected a contention from plaintiff that the more demanding de novo review standard should be applied because the Plan was only “partially-self funded.” Apparently, the plaintiff was arguing that the more rigorous standard of review should be used since the Plan had skin…

Wonderful Article by an Actuary (oxymoron?) about his First-hand Experience with Provider Fraud, Enabled by his Carrier.

Did I Produce a Catastrophic Claim or Am I a Victim of Fraud?By Michael L. FrankIt was a sunny day on December 11, 2015 when I woke up ready for a partial hip replacement. By the end of the day, I was a catastrophic claimant… or maybe a victim of fraud. You’ll be the judge. The surgery lasted less than two hours and required a one night hospital stay. In summary, I was in the hospital for…

Very Recent Opinion Finds Suit Between BCBS and Hospital Not Pre-empted Under ERISA; Relies Heavily on Stop Loss Case (BCBS v. Sharkey-Issaquena Community Hosp., Southern District of Mississippi, Dec. 13, 2017).

Very Recent Opinion Finds Suit Between BCBS and Hospital Not Pre-empted Under ERISA; Relies Heavily on Stop Loss Case (BCBS v. Sharkey-Issaquena Community Hosp., Southern District of Mississippi, Dec. 13, 2017).This is a case in which BCBS sued a Hospital and several offsite labs for allegedly reporting charges for lab work as having been done by the Hospital when in fact they were not. BCBS sued…

CASE ILLUMINATES DIFFICULTIES IN LITIGATION WITH INDIAN TRIBES IN SELF-FUNDED CONTEXT

CASE ILLUMINATES DIFFICULTIES IN LITIGATION WITH INDIAN TRIBES IN SELF-FUNDED CONTEXT (LDFS,LLC v. IEC Group, Inc., d/b/a AmeriBen, U.S. District Court, D. Arizona, July 27, 2017).A dialysis provider, LDFS, sued AmeriBen, a TPA, in federal district court in Arizona, claiming that AmeriBen owed it for services rendered to a self-funded Indian Tribe Plan beneficiary and for certain bounced checks.

HCC Won an Earlier Round in Texas Federal Court

   IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF TEXAS HOUSTON DIVISIONHCC INSURANCE HOLDINGS, INC., §Plaintiff, §§ CIVIL ACTION NO. H-15-2564§HAEL REMEIKA, §Defendant. §MEMORANDUM AND OPINIONBackgroundOn September 4, 2015, the plaintiff, HCC Insurance Holdings, Inc., sued its former senior president, Michael Remeika, for breach of contract and breach of…



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