Cases and Commentary

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…

HCC and CRU Square Off Over Former Employees’ Competition

HCC Insurance Holdings, Inc. v. Valda Flowers, et al., in the United States District Court for the Northern District of Georgia, Atlanta Division, February 22,2017.This is not strictly a stop loss case, but it does aptly illustrate what can happen when some key personnel leave a major stop loss carrier under a cloud of suspicion and begin to compete with the carrier soon after their departure.HCC…

Virginia Federal Court Relies on Virginia Economic Loss Rule to Limit Claims by Group Against Broker and TPA

Phoenix Packaging Operations LLC, et al. v. M&O Agencies, Inc., et al., No. 7:15cv569, in the United States District Court for the Western District of Virginia, June 3, 2016.Unwinding this one in a readily understandable way is no small task. But, once the issues are identified, it is, at bottom, a relatively straightforward decision involving the duties of a broker and a TPA to their client,…

Louisiana Federal Court Rejects ERISA Defense By Stoploss Carrier

Louisiana Federal Court Rejects Defendant’s ERISA Pre-emption Claims in Suit against Stop Loss Carrier (Candies Shipbuilders, LLC v. Westport Ins. Co., No. 15-1798, in the United States District Court for the Eastern District of Louisiana, February 16, 2016).This was a very easy case in my judgement. While the Court’s actual opinion is quite lengthy and detailed, the issues wer…

Florida Federal Court Keeps TPA As Third-Party Defendant in Suit Between Stop Loss Carrier and Group: A Walk Through the Procedural Thicket

Florida Federal Court Keeps TPA As Third-Party Defendant in Suit Between Stop Loss Carrier and Group: A Walk Through the Procedural Thicket (Unimerica Insurance Company v. GA Food Services, Inc., et al., No. 8:14-cv-2419-T-33TBM, In the United States District Court for the Middle District of Florida, Tampa Division, December 10, 2014)
Comment:  This case is a federal civil procedur…

Update on Undocumented Workers Stop Loss Case

Update on Undocumented Workers Stop Loss Case:  California Federal Court Enters Summary Judgment for Plaintiff on Breach of Contract Claim (Bay Area Roofers Health & Welfare Trust v. Sun Life Assurance Co., No. 13-cv-04192-BLF, November 6, 2014).
I originally reported on this case in my From the Bench article in The Self-Insurer in January 2014…



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