Health Plan Law

:: Seventh Circuit Sides With Fiduciaries On Question of Out-of-Network Disclosures

Roy F Harmon III — Fri, 20 Apr 2012 13:13:15 +0000

At the summary judgment stage of the case, the district court dismissed James’s denial-of-benefits and breach-of-fiduciary-duty claims, but awarded him minimal statutory damages against the health plan administrator. James has appealed. We hold that the district court properly granted summary judgment on James’s denial-of-benefits and breach-of-fiduciary-duty claims, but incorrectly calculated James’s statutory damages award. Killian v. Concert [...]

:: ERISA Reimbursement Claims Versus Special Needs Trusts

Roy F Harmon III — Thu, 19 Apr 2012 17:31:55 +0000

FKI and ACS rely on Bombardier for the proposition that a benefit plan can recover from a third party that is holding the funds “on behalf of a plan-participant client who is a traditional ERISA party.” Id. at 353. However, that is not the case here, because unlike the attorney in Bombardier, who was found [...]

:: When Is Exhaustion of Administrative Remedies Required? – A Reappraisal Of The Division Of Authority

Roy F Harmon III — Tue, 17 Apr 2012 10:58:21 +0000

The Court agrees with the reasoning in Morales-Cotte and finds that an exhaustion of administrative remedies is not required when a plaintiff’s claim for denial of COBRA benefits is based on a statutory violation of ERISA. Here, neither party has referred to or proffered any argument regarding a plan-based denial of COBRA benefits. The Court [...]

:: Health Care Provider “Balance Billing” Of The Personal Injury Plaintiff

Roy F Harmon III — Thu, 12 Apr 2012 00:58:37 +0000

Marcus Aurelius is a plan member of the Imperial group health plan. Imperial has contracted with Augustan, a preferred provider network or “PPO”. Augustan has in place a managed care contract with a wide variety of physicians and hospitals. Under the contact, the providers agree to accept a discounted rate in exchange for steerage [...]

:: Equitable Defense Rejected In Health Plan Reimbursement Litigation

Roy F Harmon III — Thu, 22 Mar 2012 00:40:49 +0000

Schwade’s ERISA health benefits plan (”the Plan”) declined to pay medical expenses for Schwade’s son unless Schwade complied with the Plan by signing a subrogation agreement. Schwade refused. From August to November, 2007, the Plan sent Schwade an explanation of benefits denying each claim. The Plan requires Schwade to administratively appeal a denial within 180 [...]

:: New MEWA Reporting Requirements – An Unlikely Solution To MEWA Fraud

Roy F Harmon III — Wed, 07 Mar 2012 01:36:56 +0000

The U.S. Department of Labor’s Employee Benefits Security Administration today announced a two-week extension of the comment period on its proposed rule requiring multiple employer welfare arrangements (MEWAs) to register with the department. DOL News Release (appearing here) A “MEWA” or “multiple employer welfare arrangement” consists of an employee welfare benefit plan, or any other arrangement, [...]

:: Health Care Provider’s Negligent Misrepresentation Claim Advances

Roy F Harmon III — Fri, 24 Feb 2012 16:49:42 +0000

I conclude that Rule 9(b) does not apply to the negligent misrepresentation claim before me. The crux of the claim is that Beverage failed to use reasonable care or competence in obtaining and communicating information concerning Hood’s eligibility. This rings not of fraud but negligence. See, e.g., Bloskas v. Murray, 646 P.2d 907, 914 (Colo. [...]

:: Five Year Limitations Period For COBRA Notification Lapse

Roy F Harmon III — Mon, 20 Feb 2012 23:28:59 +0000

. . . the magistrate judge followed the lead of the Fifth Circuit in Lopez ex rel. Gutierrez v. Premium Auto Acceptance, 389 F.3d 504, 507-510 (5th Cir. 2004) and cases cited therein which analogized such COBRA notice claims to unfair settlement practices claims. Such analogy is necessary, as the COBRA provision does not contain [...]

:: ERISA “Participant” Status Is Not A Jurisdictional Issue

Roy F Harmon III — Fri, 27 Jan 2012 12:21:47 +0000

Whether Leeson is a participant for purposes of ERISA is a substantive element of his claim, not a prerequisite for subject matter jurisdiction. As the Supreme Court has instructed, “when Congress does not rank a statutory limitation on coverage as jurisdictional, courts should treat the restriction as nonjurisdictional in character.” Arbaugh [...]

:: Do Benefit Plan Recoupment Claims Trigger Internal Appeal Rights?

Roy F Harmon III — Wed, 25 Jan 2012 15:05:21 +0000

Hopkins’ argument focuses on “what procedures an insurer must apply when seeking to recover an overpayment of benefits issued under ERISA health care plans.” Pl.’s Resp. at 3 (emphasis in original). She claims that defendants violated ERISA by seeking recoupment from MVH without providing her notice or an opportunity to appeal their decision to do [...]

:: Third Circuit Finds Place For Equitable Defenses To Subrogation Claims

Roy F Harmon III — Tue, 22 Nov 2011 16:33:32 +0000

Applying the traditional equitable principle of unjust enrichment, we conclude that the judgment requiring McCutchen to provide full reimbursement to US Airways constitutes inappropriate and inequitable relief. Because the amount of the judgment exceeds the net amount of McCutchen’s third-party recovery, it leaves him with less than full payment for his emergency medical bills, thus [...]

:: Forum Selection Clause Enforced In ERISA Claim Litigation

Roy F Harmon III — Mon, 01 Aug 2011 15:45:40 +0000

Plaintiff asserts that forum selection clauses are not enforceable under ERISA. In support, Plaintiff relies on a district court case from the Eastern District of Texas, Nicolas v. MCI Health & Welfare Plan No. 501, 453 F. Supp. 2d 972 (E.D. Tex. 2006). In that case, the court held that the policies of the ERISA [...]

:: Whose Privilege Is It Anyhow?

Roy F Harmon III — Tue, 12 Jul 2011 13:44:35 +0000

The fiduciary exception to the attorney-client privilegehas its roots in 19th-century English common-law casesholding that, “when a trustee obtained legal advice relating to his administration of the trust, and not in antici-pation of adversarial legal proceedings against him, thebeneficiaries of the trust had the right to the production of that advice.” Ibid. (collecting cases). The [...]

:: ERISA Section 502(a)(3) Claims Remanded For Reconsideration After Amara Opinion

Roy F Harmon III — Thu, 30 Jun 2011 13:43:28 +0000

For the reasons discussed below, we affirm the district court’s decision rejecting Plaintiffs’ claims under ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), and the district court’s dismissal of the claims of the Plaintiffs who received their distributions in the 2002-2003 Plan Years. However, we remand in part to the district court for reconsideration of the [...]

:: Employee Benefit Plans: Reported Criminal Enforcement Actions Year To Date

Roy F Harmon III — Fri, 10 Jun 2011 00:51:15 +0000

Lakewood Man Charged with Embezzlement from Employee Benefit Plan [05/06/11] Dublin Businessman Pleads Guilty to Embezzling Money from Company Pension Plan [04/15/11] Colorado Health-Plan Founder Indicted for Mail Fraud, Embezzling Plan Funds and Money Laundering [04/05/11] Founder and Treasurer of Washington D.C. Labor Union Charged with Stealing Pension Funds for Personal Use, Violating a Court Order and Obstructing Investigation [04/01/11] Michael Paul Molitor [...]

:: Supreme Court Signals Broader View of Equitable Relief Under ERISA

Roy F Harmon III — Tue, 17 May 2011 14:29:27 +0000

Why the Court embarks on this peculiar path is beyond me. It cannot even be explained by an eagerness to demonstrate — by blatant dictum, if necessary — that, by George, plan members misled by an SPD will be compensated. CIGNA Corp. v. Amara, 2011 U.S. LEXIS 3540 (U.S. May 16, 2011), SCALIA , J. [...]

:: Estoppel Claims Can Prevail Over Unambiguous Plan Language

Roy F Harmon III — Fri, 13 May 2011 02:06:34 +0000

Defendants argue that the first amended complaint is deficient because, with the exception of Count Four, which is identified as a claim for benefits pursuant to §1132(a)(1)(B), plaintiff fails to specify the ERISA statutory provisions upon which her claims are based. This argument is not well taken. A plaintiff is not required to plead legal theories [...]

:: Claims For Administrative Record And Statutory Penalties Advance Over Challenge

Roy F Harmon III — Wed, 27 Apr 2011 00:49:15 +0000

Plaintiffs bring a claim for violation of 29 C.F.R. 2560.503-1(h)(2) on behalf of the individual Plaintiffs against Defendants . . . 29 C.F.R. 2560.503-1(h)(2) sets forth the requirements that must be met in order for a plan’s claims procedures to be considered as having provided a claimant with a reasonable opportunity for a full and fair [...]

:: Organizing The FAQ’s

Roy F Harmon III — Wed, 20 Apr 2011 13:44:01 +0000

I replaced the FAQ resource page previously on this site with a new FAQ page that lists the questions with links back to the DOL site where the answers appear.

:: Is The DOL Abusing the “FAQ” Format?

Roy F Harmon III — Thu, 14 Apr 2011 01:37:10 +0000

Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of the market reform provisions of the Affordable Care Act. These FAQs have been prepared jointly by the Departments of Health and Human Services (HHS), Labor and the Treasury (the Departments). Like previously issued FAQs (available at http://www.dol.gov/ebsa/healthreform/), these FAQs answer questions from stakeholders [...]