Health Plan Law

:: Enforcement Of Equitable Liens By ERISA Benefit Plans - A Contrast In Available Remedies

Roy F Harmon III — Wed, 11 Nov 2009 22:00:57 +0000

In this case, Ms. Powell did not commingle her funds and made no purchases that diminished in value. Thus, the “conscious wrongdoer” standard has no application. Moreover, in Sereboff the Supreme Court stated, “This rule allowed them to follow a portion of the recovery into the [Sereboff's] hands as soon as [the settlement fund] was [...]

:: H.R. 3962 Passes By Narrow Vote

Roy F Harmon III — Mon, 09 Nov 2009 14:33:22 +0000

H.R. 3962, the House health care bill, passed by a vote of 220 - 215. Changes to the original bill were required to obtain the necessary votes. Highlights of some of the changes are highlighted in this summary prepared by the House Committees on Ways & Means, Energy & Commerce, Education & Labor. This clinical, upbeat [...]

:: Fact Check #4: “Endorsements” Of Health Care Legislation Are Deceiving

Roy F Harmon III — Sat, 07 Nov 2009 02:26:08 +0000

It’s an open secret in Washington that only about 15-20 percent of doctors are members of the AMA. Sermo, a 110,000-member, non-partisan online community of doctors — 25 percent of whom say they are members of the AMA — has recently released polls showing that 92 percent of doctors don’t think the Democratic bills address [...]

:: Defensive ERISA Preemption Inadequate To Sustain Removal Of Subrogation Dispute

Roy F Harmon III — Thu, 05 Nov 2009 12:32:52 +0000

Following an automobile accident, Plaintiffs Richard and Pamela Cottrill filed suit in the Court of Common Pleas of Perry County against Allstate Insurance Company (”Allstate”) and Blue Cross Blue Shield of Michigan (”Blue Cross”). In addition to seeking damages against Allstate, Plaintiffs asked the court to declare the rights and obligations of the parties to [...]

:: A Primer On Venue Choice In ERISA Claim Disputes

Roy F Harmon III — Wed, 04 Nov 2009 12:01:40 +0000

Plaintiffs originally filed their complaint in the Court of Common Pleas of Philadelphia County, Pennsylvania. Defendants then removed the action to federal court. The plaintiffs’ choice of venue is generally accorded great weight, but other factors such as where the underlying events occurred and where the plaintiffs reside can override this concern. Schoonmaker v. Highmark Blue [...]

:: Seventh Circuit Holds Disability Benefits Claim Incompatible With ADA Claims

Roy F Harmon III — Wed, 28 Oct 2009 13:44:09 +0000

Claiming disability benefits and asserting ADA claims are not always mutually exclusive, but a “plaintiff’s sworn assertion in an application for disability benefits that she is, for example, ‘unable to work’ will appear to negate an essential element of her ADA case–at least if she does not offer a sufficient explanation.” Cleveland v. Policy Mgmt. [...]

:: Plan Language Sufficient To Authorize Settlement Of ERISA Benefit Claims With TCA’s

Roy F Harmon III — Tue, 27 Oct 2009 13:51:02 +0000

Thus, the fact that the Kodak and GM Plans provided for distribution of death benefits through the establishment of a TCA, and that MetLife complied with those provisions, does not in itself immunize MetLife from liability here. What does prevent a claim for breach of fiduciary duties here, however, is the simple fact that Plaintiffs [...]

:: First Circuit Finds Plan Language Adequate For Delegation Of ERISA Fiduciary’s Authority

Roy F Harmon III — Thu, 22 Oct 2009 03:34:19 +0000

In this case, the Plan gives its named fiduciary- the Pension Committee–express power to “exercise its discretion” to decide on benefits, construe the Plan and render binding decisions. Unquestionably, the Pension Committee purported to delegate to Corporate Benefits this authority by a 1998 written instrument. Wallace, however, argues that the delegation is invalid because allegedly the [...]

:: Joint Venture Liability For Medical Stop Loss Claims

Roy F Harmon III — Thu, 15 Oct 2009 12:46:07 +0000

Majestic has included RMTS as a defendant in Count I (declaratory relief), Count II (breach of contract), and Count IV (bad faith). RMTS argues that it should be “dismissed” from this action because it was not a party to the stop loss contracts. Majestic counters that RMTS is a proper defendant because it is a [...]

:: Missed COBRA Qualifying Events Cause Forfeiture Of Stop Loss Coverage

Roy F Harmon III — Tue, 13 Oct 2009 23:45:30 +0000

In Fenner, this court held that if the same medical coverage continues automatically after termination, no qualifying event occurs. 25 F. Supp. 2d at 873 (citing Mansfield v. Chicago Park Dist. Group Plan, 997 F. Supp. 1053 (N.D. Ill. 1998). But, if the health plan requires the employee to take any action to continue her [...]

:: ERISA Plan’s Subrogation Rights Enforceable Against Workers’ Compensation Award

Roy F Harmon III — Thu, 08 Oct 2009 14:44:50 +0000

In Local 705 Int’l Bhd. of Teamsters Health & Welfare Fund v. Bilal, 2009 U.S. Dist. LEXIS 87090 (N.D. Ill. Sept. 22, 2009) the employee suffered two head injuries, one in January 2003 and the other which was sustained at work on November 21, 2003. On or about January 22, 2004, a workers’ Compensation claim was [...]

:: Health Care Economics - Why Prices ≠ Costs & Why That Matters

Roy F Harmon III — Wed, 07 Oct 2009 11:17:56 +0000

Prices are not costs. Prices are what pay for costs. Where the costs ar not covered by the prices that are allowed to be charged, the supply of the goods or services simply tends to decline in quantity or quality . . . Thomas Sowell, “Basic Economics : A Common Sense Guide to the Economy” (3rd [...]

:: Eleventh Circuit Upholds ERISA’s Plan’s Benefit Denial Under Doyle Test

Roy F Harmon III — Mon, 05 Oct 2009 13:17:20 +0000

We have required courts to employ a six-step analysis “for use in judicially reviewing virtually all ERISA-plan benefit denials.” Williams v. BellSouth Telecomms., 373 F.3d 1132, 1137-38 (11th Cir. 2004). We have described step 3 of the six-step analysis as follows: “If the administrator’s decision is ‘de novo wrong’ and he was vested with discretion [...]

:: Tenth Circuit Notes Circuit Split On Contractual Limitations Periods

Roy F Harmon III — Fri, 02 Oct 2009 16:29:29 +0000

ERISA does not contain a limitations provision for private enforcement actions under 29 U.S.C. § 1132. Thus, we generally “apply the most closely analogous statute of limitations under state law.” “Choosing which state statute to borrow is unnecessary, however, where the parties have contractually agreed upon a limitations period.” Salisbury v. Hartford Life & Accident Ins. [...]

:: Written Plan Requirement Defeats Breach Of Fiduciary Duty Claims

Roy F Harmon III — Thu, 01 Oct 2009 10:06:15 +0000

“[O]ral promises are unenforceable under ERISA and therefore cannot vary the terms of an ERISA plan.” Perreca v. Gluck, 295 F.3d 215, 225 (2d Cir. 2002); see also 29 U.S.C. § 1102(a)(1) (”Every employee benefit plan shall be established and maintained pursuant to a written instrument . . . .”). For this reason, we held [...]

:: Balance Billing Practices May Constitute Breach of Contract

Roy F Harmon III — Wed, 30 Sep 2009 12:28:22 +0000

rThe Hornings contend that their contract with the PPO provides that in return for the premiums they pay, the PPO makes payments to the providers on their behalf in accordance with the PPO’s contract with the provider. Moreover, the contract the PPO has with the provider ensures that the provider accepts payment at a discounted [...]

:: New Scholarship Analyzes Cost Allocation Of Medical Coverage

Roy F Harmon III — Tue, 29 Sep 2009 14:56:31 +0000

Edward A. Zelinsky, Morris and Annie Trachman Professor of Law, Benjamin N. Cardozo School of Law delivered the Dr. Arthur Grayson Distinguished Lecture at Southern Illinois University last week. This lecture will be published in the Journal of Legal Medicine. Here’ is the abtract: Whatever happens in Washington in the weeks and months ahead, the United States [...]

:: Where ERISA And Workers’ Compensation Claims Intersect - An Insider’s Guide

Roy F Harmon III — Tue, 29 Sep 2009 01:18:21 +0000

It’s a well known fact among workers’ compensation attorneys that employer group health plans frequently pay medical claims that probably should have been paid by the comp carrier. This shift in liability is not always simply a case of money being moved from one pocket to another. In many cases employer self-funded group health plans are [...]

:: New Scholarship Provides Group Actuarial Perspectives On Health Plan Populations

Roy F Harmon III — Fri, 25 Sep 2009 11:33:06 +0000

An article by David M. Cutler , Bryan Lincoln and Richard J. Zeckhauser examines group actuarial issues that affect health plan populations. Here is the article abstract: This study assesses the factors influencing [...]

:: Health Plan Law Now On Twitter

Roy F Harmon III — Thu, 24 Sep 2009 22:24:27 +0000

You can now follow Health Plan Law on Twitter. Here’s the link: http://www.twitter.com/healthplanlaw Also, if you have subscribed and are not getting the Health Plan Law newsletter, please let me know.