RICHMOND, Va. — Ruling that trustees of a health plan governed by the Employee Retirement Income Security Act abused their discretion in part by relying on an independent medical review (IMR) for which the plan had not provided relevant medical records, a Fourth Circuit U.S. Court of Appeal panel on April 20 affirmed a grant of summary judgment to the claimant and a lower court’s outright award of benefits.
TRENTON, N.J. — Mental health and substance abuse providers continue to rely on the same conclusory statements about assignment of rights to vaguely defined “providers” and unidentified plan terms allegedly entitling them to additional compensation, a federal judge in New Jersey said April 19 in dismissing an action with prejudice.
DENVER — A court should not avoid a merits ruling but instead affirm an insurer’s conclusion that further treatment at a long-term residential treatment facility was not medically necessary, and the 10th Circuit U.S. Court of Appeals should reject the Department of Labor’s attempt to rewrite Employee Retirement Income Security Act regulations in an amicus curiae brief, an insurer and an industry group told the court in a pair of April 15 briefs.
ASHEVILLE, N.C. — A man found to have been improperly denied proton beam radiation therapy by his insurer told a federal judge in North Carolina on April 12 that the specialized work generally involved in Employee Retirement Income Security Act cases and health care in particular warranted in excess of $220,000 in attorney fees.
AUSTIN, Texas — The Texas Supreme Court on April 15 asked parties for additional briefing about whether a subject matter jurisdiction challenge is the proper vehicle for litigating a dispute over statutory construction and whether a law governing reimbursement for emergency care contains a private right of action.
WASHINGTON, D.C. — The U.S. Supreme Court on April 18 turned away a deaf woman’s petition asking whether the Patient Protection and Affordable Care Act discrimination provision permits nominal damages.
SAN FRANCISCO — A California federal judge on April 13 dismissed in part with leave to amend a complaint brought by mental health and substance abuse health care providers who accuse an insurer of violating California’s unfair competition law (UCL) and of committing fraud by allegedly denying coverage for “medically necessary” services for patients, most of whom are insured under plans governed by the Employee Retirement Income Security Act.
SAN FRANCISCO — A Ninth Circuit U.S. Court of Appeals panel on April 13 affirmed a district court’s grant of summary judgment to a health insurance company in a suit filed by the wife of a deceased Medicare patient against the company regarding its administration of her deceased husband’s Medicare Advantage (MA) plan, finding that the Medicare Act’s “express preemption provision” barred her state law claims.
SAN ANTONIO — Insurance-related defendants have not shown that an insured could not recover from a provider for allegedly misrepresenting insurance coverage for a double hip replacement, which defeats complete diversity and requires remanding the insured’s action, a federal magistrate judge in Texas said April 12 in recommending granting the insured’s remand motion.
WASHINGTON, D.C. — New regulatory guidance shows that the government plans on doubling down on its litigation position despite recent precedent enjoining provisions of the No Surprises Act, air transport plaintiffs told a federal judge in the District of Columbia on April 12.
KANSAS CITY, Kan. — An insurer assuming responsibility for Blue Cross Blue Shield of Kansas Inc.’s (BCBSKS) insolvent excess errors and omissions insurer on March 31 opposed BCBSKS’s motion for judgment on the pleadings in a Kansas federal court, refuting the health insurer’s challenge to two claims in an antitrust coverage dispute.
SAN FRANCISCO — A Ninth Circuit U.S. Court of Appeals panel on April 8 affirmed a district court’s dismissal of an air ambulance service’s claims for violation of California’s unfair competition law (UCL) and breach of contract against an insurer over its claims for transport of patients from Mexico to the United States, ruling that the company failed to exhaust administrative remedies under the Medicare Act before suing.
TRENTON, N.J. — An out-of-network surgery provider points to no Employee Retirement Income Security Act plan provision requiring an insurer to compensate it at a higher rate, a federal judge in New Jersey said in dismissing a case April 1.
CHICAGO — Parties on April 7 filed a joint status report in a lawsuit alleging that insurance brokers breached their duty of care because they knew or should have known that a multiple employer welfare arrangement (MEWA) was not in compliance with its structural requirements and was not financially sound, indicating that the parties have issued a total of 87 third-party document subpoenas and that the plaintiff has now settled with five of the defendants.
HOUSTON — A district court erred in finding that preemption and standing issues precluded a case challenging an insurer’s denial of coverage for proton beam radiation therapy, a federal employee tells the Fifth Circuit U.S. Court of Appeals in an April 6 brief.
WASHINGTON, D.C. — Whether a court should immediately rule on a challenge to the No Surprises Act to avoid wasting economic and judicial resources or wait for a forthcoming rule that will refine the process of determining how mediators decide the appropriate compensation for such providers came before a District of Columbia federal judge on April 4 in supplemental briefing.
CINCINNATI — De novo review applies to objections to a magistrate judge’s report, and the record shows that an insurer failed to properly explain the basis for denying coverage for lumbar decompression and discectomy, lacked the entire medical record before making its decision, deviated from the plan in relying on a single standard for its decision and improperly ignored a second-level appeal in an Employee Retirement Income Security Act case, a federal judge in Ohio said March 23 in adopting the report.
WASHINGTON, D.C. — Insolvent insurers and the U.S. government on March 31 filed a corrected stipulation for entry of partial judgment in the U.S. Court of Federal Claims based on their settlement of a lawsuit seeking a declaratory judgment that the U.S. government owes the insurers millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program.
ATLANTA — A hospital presented no evidence in support of its request for injunctive relief precluding cancellation of an insurance contract, but even if it had, the state law prohibiting cancellation of such contracts is not in effect because the governor has not declared a public health emergency as required by the law, an insurer told the Georgia Supreme Court on March 8.
WASHINGTON, D.C. — Allowing nominal damages after a liability finding in health care discrimination cases would resolve a circuit split on the issue and eases the process of determining attorney fees and other costs based on the prevailing party, a deaf woman told the U.S. Supreme Court in urging it to grant review on March 29.