DETROIT — The passage of more than 100 days since a court remanded an Employee Retirement Income Security Act case for a benefits determination warrants finding administrative remedies exhausted and reopening a case, a couple tells a federal judge in Michigan in a Jan. 2 brief. But in a response filed the same day, the insurer argues that a determination is forthcoming (Paul Zack, et al. v. McLaren Health Advantage Inc., No. 17-11253, E.D. Mich.).
FORT WORTH, Texas — A federal judge in Texas entered final judgment on his ruling that Congress’ elimination of the penalty for individual mandate noncompliance rendered the entire Patient Protection and Affordable Care Act (ACA) unconstitutional and on Dec. 31 stayed the remainder of the case, paving the way for an appeal (Texas, et al. v. U.S.A., et al., No. 18-167, N.D. Texas).
WASHINGTON, D.C. — A federal judge in the District of Columbia on Dec. 12 granted preliminary approval to a class action settlement providing for full payment of out-of-pocket expenses allegedly incurred by a health insurer’s failure to cover comprehensive breastfeeding and lactation support counseling in violation of the Patient Protection and Affordable Care Act (ACA) (Lindsay Ferrer, et al. v. CareFirst Inc., et al., No. 16-2162, D. D.C.).
NEWARK, N.J. — An anti-assignment provision in a health care insurance contract is not subject to an alternative interpretation that could create ambiguity and was not waived, a federal judge in New Jersey held Dec. 14 in dismissing a provider’s case (Advanced Orthopedics and Sports Medicine Institute v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-8848, D. N.J.).
SAN FRANCISCO — HIV/AIDS drug purchasers who allege that a health insurer violated their privacy and discriminated against them by requiring the use of mail order or pickup services fail to state claims under the Patient Protection and Affordable Care Act (ACA), California unfair competition law (UCL) or Employee Retirement Income Security Act, a federal judge in California held Dec. 12 (John Doe One, et al. v. CVS Pharmacy Inc., et al., No. 18-1031, N.D. Calif.).
LOS ANGELES — A company appears to properly have purchased claims from medical providers, but it cannot show that the claims it pursues are covered by the purchase agreement, and it has not adequately pleaded its claims, a federal judge in California held Dec. 7 (Namdy Consulting Inc. v. UnitedHealthcare Insurance Co., No. 18-1283, C.D. Calif., 2018 U.S. Dist. LEXIS 208890).
JACKSON, Tenn. — A trial court correctly concluded that individual issues predominate over a proposed class action challenging an insurer’s use of a $50 cap on reimbursement for nonemergency services provided in the emergency room, the majority of a Tennessee appeals court held Nov. 29 (Emergency Medical Care Facilities P.C. v. BlueCross BlueShield of Tennessee Inc., et al. No. W2017-02211-COA-R3-CV, Tenn. App., 2018 Tenn. App. LEXIS 695).
TRENTON, N.J. — An out-of-network medical provider’s “unique” conspiracy suit involving 14 causes of action against 17 defendants does not invoke the right to payment under the Employee Retirement Income Security Act and sufficiently alleges the existence of an independent legal duty, a federal judge in New Jersey held in remanding the action on Dec. 14 (North Jersey Brain & Spine Center v. MultiPlan Inc., et al., No. 17-5967, D. N.J., 2018 U.S. Dist. LEXIS 211272).
SAN FRANCISCO — A divided Ninth Circuit U.S. Court of Appeals on Dec. 13 partially upheld a ruling enjoining new Patient Protection and Affordable Care Act (ACA) contraceptive mandate exemptions expanding who can avoid the regulation, but said nonparty states could not be subject to the injunction (California, et al. v. Alex M. Azar II, et al., Nos. 18-15144, 18-15166, 18-15255, 9th Cir., 2018 U.S. App. LEXIS 35077).
FORT WORTH, Texas — A federal judge in Texas said striking the Patient Protection and Affordable Care Act (ACA) individual mandate renders the entire law unconstitutional under Supreme Court precedent. The Dec. 14 ruling throws the law in doubt just as the window for enrollment closes for 2018 and means that the law is likely headed back to the Supreme Court (Texas, et al. v. U.S.A., et al., No. 18-167, N.D. Texas).
SAN FRANCISCO — A health insurer did not abuse its discretion in concluding that a California minor’s involuntary residential psychiatric treatment in Utah was not performed on an emergency basis or that her mother failed to properly investigate the potential for in-area, in-network care before the admission, a federal judge in California held Dec. 11 (Carol Meyers v. Kaiser Foundation Health Plan Inc., No. 17-04946, N.D. Calif.).
LAS CRUCES, N.M. — An air transport’s challenge to New Mexico’s law precluding balance billing stems from a ruling in a review involving an insured and insurer and is not properly before the court, a federal judge in New Mexico said Dec. 10 (Phi Air Medical LLC v. New Mexico Office of Superintendent of Insurance, et al., No. 18-382, D. N.M., 2018 U.S. Dist. LEXIS 207895).
NEW YORK — Health insurers due money under the Patient Protection and Affordable Care Act (ACA) risk-adjustment program and New York state faced off in Dec. 10 simultaneous briefing in the Second Circuit U.S. Court of Appeals over whether New York could lay claim to some of those proceeds under its own risk-adjustment program (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).
BOSTON — A health insurance plan’s exclusion for custodial care unambiguously includes the wilderness therapy treatments at the heart of three plaintiffs’ ERISA suit, a federal judge in Massachusetts said Dec. 6 (David Cotton, et al. v. Blue Cross and Blue Shield of Massachusetts HMO Blue Inc., et al., No. 16-12176, D. Mass., 2018 U.S. Dist. LEXIS 205869).
BILLINGS, Mont. — A woman’s claim seeking to recover additional payments from her health insurer for air transport is timely under the ambiguous terms of the plan, she has standing under the Employee Retirement Income Security Act and her claims support a breach of fiduciary duty claim, a federal judge in Montana held Dec. 3 in largely permitting her suit to proceed (Jennifer Tawater v. Health Care Services Corp., et al., No. 18-47, D. Mont., 2018 U.S. Dist. LEXIS 204309).
TRENTON, N.J. — An insured adequately alleges entitlement to additional coverage for out-of-network care under his plan’s emergency services provision, but not how his insurer’s payment would violate that provision, a New Jersey federal judge said Nov. 30 (Clifford Robinson v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J., 2018 U.S. Dist. LEXIS 202887).
SAN DIEGO — Allegations that a man paid higher prices for generic drugs as a result of a pharmacy’s two-tiered pricing scheme give him standing and adequately allege a California unfair competition law (UCL) violation for unfair conduct, but several of his claims appear untimely and must be dismissed, a federal judge in California held Nov. 20 (Robert Josten, et al. v. Rite Aid Corp., No. 18-152, S.D. Calif., 2018 U.S. Dist. LEXIS 198124).
YAKIMA, Wash. — A woman’s class action claiming that her health care insurer misrepresented the coverage and provider network its policy provided does not ask the court to review agency-established premiums and adequately alleges breach of contract and violation of state consumer protection law, a federal judge in Washington state held Nov. 21 (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash., 2018 U.S. Dist. LEXIS 198773).
TRENTON, N.J. — A medical provider’s pursuit of reimbursement stands or falls on the strength of its state law causes of action and belongs in state court, a federal judge in New Jersey held Nov. 26 in adopting a recommendation that the case be remanded (East Coast Advanced Plastic Surgery v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 18-7718, D. N.J., 2018 U.S. Dist. LEXIS 199891).
TRENTON, N.J. — The conclusion that not all of an insurer’s overpayment letters to medical providers constituted a demand for payment or adverse benefit denial made class certification of plaintiffs’ Employee Retirement Income Security Act claims improper, a federal judge in New Jersey held in denying reconsideration on Nov. 26 (Association of New Jersey Chiropractors, et al. v. Aetna Inc., et al., TRI3 Enterprises LLC, et al. v. Aetna Inc., et al., Nos. 09-3761, 11-3921, D. N.J., 2018 U.S. Dist. LEXIS 199431).