SEATTLE — An insurer erred when it denied coverage for proton beam therapy as not medically necessary to treat for a man’s prostate cancer, a divided Washington Supreme Court held Oct. 3 (John Strauss, et al. v. Premera Blue Cross, No. 74600-6-I, Wash. Sup., 2019 Wash. LEXIS 593).
NEW YORK — Whether assignment of Employee Retirement Income Security Act rights requires reversing class certification of a group of surgery providers claiming that the insurer denied payment for facility fees without regard for whether coverage existed under specific plan language came before a New York federal judge on Oct. 14 as the parties briefed a motion for reconsideration (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y.).
WASHINGTON, D.C. — If a state court may simply deny a federally mandated right to a Medicaid hearing, it is in reality no right at all, a woman argues in a reply brief as the U.S. Supreme Court justices prepare to convene and consider her petition for a writ of certiorari on Oct. 18 (Lettie Sexton, et al. v. Kentucky, et al., No. 18-1446, U.S. Sup.).
TRENTON, N.J. — Recent Third Circuit U.S. Court of Appeals precedent finding anti-assignment provisions in Employee Retirement Income Security Act health plans enforceable strips a court of jurisdiction over a health care reimbursement case and precludes the court from considering the insured’s belated power of attorney arguments, a federal judge in New Jersey said Oct. 2 (University Spine Center, et al. v. Anthem Blue Cross Blue Shield, No. 17-11725, D. N.J., 2019 U.S. Dist. LEXIS 170788).
NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals denied a motion for rehearing Oct. 10, letting stand a decision finding a health care plan’s anti-assignment provision prevented a health care provider from suing an insurer (Dialysis Newco Inc., et al. v. Community Health Systems Group Health Plan, et al., No. 18-40863, 5th Cir.).
NEW YORK — The United States’ amicus brief leaves no question about whether New York’s risk-adjustment program violates the Patient Protection and Affordable Care Act (ACA), an insurer tells the Second Circuit U.S. Court of Appeals in a Sept. 23 brief. But New York says in its own letter brief that the panel should ignore the government’s attempt to recharacterize its earlier position (UnitedHealthcare of New York Inc., et al. v. Linda Lacewell, et al., No. 18-2583, 2nd Cir.).
DALLAS — A limited partnership filed suit in Texas federal court on Oct. 4, seeking to force the U.S. Department of Labor (DOL) to issue an advisory opinion declaring that the self-insured health plan it offers common-law employees and limited partners is not a multiple welfare arrangement (MEWA) under the Employee Retirement Income Security Act (Data Marketing Partnership LP v. United States Department of Labor, et al., No. 19-800, N.D. Texas).
WASHINGTON, D.C. — Colorado insurance liquidation law precludes the U.S. Department of Health and Human Services (HHS) from using money owed to an insolvent Colorado insurer to pay debts owed under the Patient Protection and Affordable Care Act’s (ACA) reinsurance and risk-adjustment programs, a judge in the U.S. Court of Federal Claims ruled Oct. 3 (Michael Conway v. The United States, No. 18-1623, Fed. Clms., 2019 U.S. Claims LEXIS 1306).
WASHINGTON, D.C. — The U.S. Supreme Court on Oct. 7 denied a health care insurer’s petition for review, leaving stand a Fifth Circuit U.S. Court of Appeals ruling finding that direct payments to a provider waived an Employee Retirement Income Security Act plan’s anti-assignment provision protections (Louisiana Health Service & Indemnity Co. v. Encompass Office Solutions, Inc., No. 19-196, U.S. Sup.).
HARTFORD, Conn. — A class of Medicare recipients in a Sept. 19 post-trial brief tell a Connecticut federal court that they have been deprived of a protected property interest by state action without due process of law and that the failure of the secretary of Health and Human Services to allow them to appeal to Medicare the issue of the classification of their hospital services under Medicare rules violates the Fifth Amendment’s due process clause (Christina Alexander, et al. v. Alex M. Azar II, No. 11-1703, D. Conn.).
BROOKLYN, N.Y. — Conflicting medical opinions and evidence do not support the conclusion that an insurer acted improperly when it denied coverage for mental health treatments after a suicide attempt, a New York judge held Sept. 30 in adopting a magistrate judge’s report and recommendation (Samuel Halberg, et al. v. United Behavioral Health, et al., No. 16-6622, E.D. N.Y., 2019 U.S. Dist. LEXIS 169679).
SALT LAKE CITY — A man who claims that he spent $340,000 on his daughter’s mental health treatments after an insurer improperly denied coverage has standing but has not adequately alleged a violation of the Mental Health Parity and Addiction Equity Act, a federal judge in Utah said Sept. 27 (Jeff N., et al. v. United Healthcare Insurance Co., No. 18-710, D. Utah, 2019 U.S. Dist. LEXIS 167420).
SALT LAKE CITY — A family’s class action allegations involving the denial of coverage for wilderness treatment under an Employee Retirement Income Security Act health plan are duplicative or fail to state a claim, but their claims involving allegedly disparate treatment in the mental health setting may continue, a federal judge in Utah said Sept. 27 (K.H.B., et al. v. UnitedHealthCare Insurance Co., No. 18-795, D. Utah, 2019 U.S. Dist. LEXIS 167183).
NEW ORLEANS — A dialysis provider in a Sept. 25 petition asks the Fifth Circuit U.S. Court of Appeals to review a Sept. 11 panel ruling finding that a health care plan precluded assignment of Employee Retirement Income Security Act rights and that ERISA preempted a Tennessee statute making insurers liable to third-party providers (Dialysis Newco Inc., et al. v. Community Health Systems Group Health Plan, et al., No. 18-40863, 5th Cir.).
NEW YORK — A health insurer in a Sept. 25 memo asks a federal judge in New York to reconsider a Sept. 11 ruling that allegations that the insurer improperly denied coverage for out-of-network facility fees for certain providers supported certification of a class seeking declaratory and injunctive relief, but not classwide benefit awards, contending that determining whether providers properly obtained an assignment of rights under Employee Retirement Income Security Act plans requires claim-by-claim analysis precluding certification (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y.).
CINCINNATI — A health insurance administrator’s decision to make all dialysis companies out-of-network providers does not violate the Medicare Secondary Payor Act (MSPA), and the provider’s assignment is limited to insurance benefits and does not include the right to litigate, a federal judge in Ohio held Sept. 20 (DaVita Inc., et al. v. Marietta Memorial Hospital Employee Health Benefit Plan, et al., No. 18-1739, S.D. Ohio, 2019 U.S. Dist. LEXIS 160793).
TRENTON, N.J. — A man’s “completely unsubstantiated” allegations seeking usual and customary medical expenses for which his plan clearly does cover warrant an award of attorney fees, but the plan sponsor must submit more evidence demonstrating that its requested fees constitute reasonable charges, a federal judge in New Jersey held Sept. 24 (Clifford Robinson v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J., 2019 U.S. Dist. LEXIS 162702).
NEW ORLEANS — A federal judge in Louisiana largely rejected a couple’s Employee Retirement Income Act claims in Sept. 19 and 24 rulings and found that the law’s conflict preemption statute doomed the state law claims (Soileau & Associates LLC, et al. v. Louisiana Health Service & Indemnity Co., Nos. 18-310, 18-7613, E.D. La., 2019 U.S. Dist. LEXIS 159622).
NEW YORK — Allegations that health care providers treated individuals in government and church plans outside the reach of the Employee Retirement Income Security Act precludes preemption, and while the breach of contract claim survives, the remaining 10 claims are largely duplicative and must be dismissed, a federal judge in New York held Sept. 17 (Perry A. Frankel, et al. v. U.S. Healthcare Inc., et al., No. 18-6378, S.D. N.Y., 2019 U.S. Dist. LEXIS 159794).
WASHINGTON, D.C. — The U.S. Supreme Court lacks jurisdiction over a Kentucky top court ruling on standing, and nothing in a ruling precluding a hearing after an insurer denied coverage under Medicaid would warrant review, the insurer tells the court in a Sept. 19 respondent brief (Lettie Sexton, et al. v. Commonwealth of Kentucky, et al., No. 18-1446, U.S. Sup.).