Mealey's Health Care / ACA

  • March 08, 2022

    Judge Dismisses ‘Cosmetic’ Transgender Procedure Coverage Suit

    FRANKFURT, Ky. — A health insurance policy’s exclusion on cosmetic reconstructive surgeries does not violate Employee Retirement Income Security Act guidelines or the preclusion on discrimination in either that statute or the Patient Protection and Affordable Care Act (ACA), a federal judge in Kentucky said Feb. 23 in dismissing a gender dysphoria sufferer’s claims.

  • March 07, 2022

    Parties File Stipulation Over Extending Substance Abuse Payment Case Discovery

    LOS ANGELES — Medical providers and insurer entities squared off in a joint stipulation March 3 in California federal court over whether to extend the deadline for discovery in a case over reimbursement for out-of-network substance abuse care.

  • March 04, 2022

    Judge Grants Summary Judgment Against Plaintiff In ERISA, RICO Row Over Drug Prices

    WHITE PLAINS, N.Y. — Finding no genuine dispute of material fact that the defendants “complied with the negotiated terms” of a health insurance plan, a New York federal judge on Feb. 22 granted summary judgment against the plaintiff in a putative class suit over prescription drug prices, ruling that all claims under the Employee Retirement Income Security Act and the  Racketeer Influenced and Corrupt Organizations Act (RICO) must be dismissed.

  • March 04, 2022

    S.C. Court: Insured May Sue Provider As Beneficiary Of Insurer-Provider Contract

    COLUMBIA, S.C. — An insured is the third-party beneficiary of a contract between a medical provider and her insurer and may pursue her claim that the provider improperly billed her at a nondiscounted rate in violation of the contract, the South Carolina Supreme Court said Feb. 22.

  • March 03, 2022

    Insurer Says No Basis For Wilderness Exclusion Coverage Suit

    SEATTLE — The Washington Parity Act excluded residential treatments when a woman underwent her treatments, and at most, federal law would replace, not alter, those requirements, but it provides no private right of action on which to pursue a claim, an insurer told a Washington appeals court on Feb. 4.

  • March 03, 2022

    Judge: Hearing Loss Coverage Exclusion Doesn’t Constitute Proxy Discrimination

    SEATTLE — Allegations that hearing loss affects a range of individuals and that an insurer’s exclusion on most hearing loss treatments acts as a form of proxy discrimination fail to meet the standard recently announced by the Ninth Circuit U.S. Court of Appeals for discriminatory benefit design under the Patient Protection and Affordable Care Act (ACA), a federal judge in Washington said Jan. 31.

  • March 03, 2022

    DOL Weighs In On 10th Circuit Appeal Over Residential Treatment Denial

    DENVER — A lower court applied the correct legal framework in assessing whether an insurer’s denial of a claim for residential treatment benefits was arbitrary and capricious, the U.S. solicitor of Labor tells the 10th Circuit U.S. Court of Appeals in a Feb. 23 amicus curiae brief; on March 2, the court clerk referred a dispute over correcting the appendix that was filed in the appeal to the merits panel.

  • March 01, 2022

    High Court Hears Arguments In Dialysis Compensation Case

    WASHINGTON, D.C. — A health care provider told the U.S. Supreme Court March 1 during oral argument that a plan’s handling of dialysis compensation constitutes an improper effort at shifting the cost of treatments to Medicare that threatens the entire industry, while the United States and an insurer argued that the plan language applies equally among all insureds and is therefore not discriminatory under the Medicare Secondary Payor Act (MSPA).

  • March 01, 2022

    4th Circuit Partially Vacates Judgment For Insurer In Residential Treatment Case

    RICHMOND, Va. — A father seeking insurance coverage for two years of residential treatment for his son through his work-provided insurance plan may proceed with a portion of his claims after showing that the insurer failed to comply with the Employee Retirement Income Security Act or the plan when it did not respond to a request containing a potentially defective Health Insurance Portability and Accountability Act of 1996 (HIPAA) authorization form that sought documents upon which a denial had been based for a portion of the treatment, a Fourth Circuit U.S. Court of Appeals panel ruled Feb. 24, resetting the clock so that a compliant form may be provided and an appeal pursued.

  • February 28, 2022

    Judge Vacates Portions Of Rule Governing No Surprises Act Law

    TYLER, Texas — A federal judge in Texas on Feb. 23 awarded summary judgment to plaintiffs and vacated portions of a rule outlining the arbitration process in the No Surprises Act, finding that the plaintiffs alleged sufficient injury, that the rule improperly weighted one of the five factors laid out in the law and that the defendant agencies improperly evaded the notice-and-comment period.

  • February 28, 2022

    U.S. Supreme Court Won’t Review 5th Circuit’s ERISA Benefit Denial Review Standard

    WASHINGTON, D.C. — The U.S. Supreme Court on Feb. 28 denied a father’s petition for a writ of certiorari regarding the Fifth Circuit U.S. Court of Appeals’ application of abuse of discretion and substantial-evidence standards when reviewing health plan benefit denials under the Employee Retirement Income Security Act.

  • February 25, 2022

    5th Circuit Certifies Private Right Of Action Question To Texas Supreme Court

    HOUSTON — Citing factors including “the closeness of the question,” a Fifth Circuit U.S. Court of Appeals panel on Feb. 23 certified a question to the Texas Supreme Court, asking whether sections in Texas’ emergency care law create an implied private right of action under which emergency doctors can sue an insurer for allegedly failing to reimburse them “for out-of-network emergency care at a ‘usual and customary’ rate.”

  • February 24, 2022

    Judge Overrules Blue Cross’ Objections To Discovery Order In Antitrust Coverage Suit

    KANSAS CITY, Kan. — A federal judge in Kansas on Feb. 22 overruled Blue Cross Blue Shield of Kansas Inc.’s objection to a Kansas federal magistrate judge’s discovery order in an antitrust coverage dispute involving an insolvent insurer, finding that while Blue Cross strongly disagrees with the magistrate’s conclusions, it has not demonstrated that the conclusions are contrary to law.

  • February 23, 2022

    Judge Enters Judgment On Insolvent Insurer’s Subrogation Claim In Antitrust Dispute

    KANSAS CITY, Kan. — A federal judge in Kansas on Feb. 15 granted Blue Cross Blue Shield of Kansas Inc.’s insolvent excess errors and omissions insurer’s motion for entry of a Rule 54(b) judgment on a subrogation claim against Blue Cross Blue Shield Association in an antitrust coverage dispute, finding that “there is no just reason” to delay appellate review.

  • February 22, 2022

    Government Seeks Time To Respond In Medicare Advantage Dispute

    WASHINGTON, D.C. — The government on Feb. 18 asked the U.S. Supreme Court for more time to respond to a petition challenging an opinion finding that federal regulations make Medicare Advantage insurers liable for reimbursing the program when diagnostic codes don’t match the services provided.

  • February 18, 2022

    High Court Asked To Consider 5th Circuit’s ERISA Benefit Denial Review Standard

    WASHINGTON, D.C. — In a certiorari petition filed Jan. 24 with the U.S. Supreme Court, a father argues that the Fifth Circuit U.S. Court of Appeals’ application of abuse of discretion and substantial-evidence standards when reviewing health plan benefit denials under the Employee Retirement Income Security Act conflicts with high court precedent; on Feb. 3, the respondents waived their right to respond.

  • February 18, 2022

    Judge: Insurer’s Ultimate Payment For Clinical Trial Moots ERISA Case

    WEST PALM BEACH, Fla. — An insurer’s about-face decision to cover a woman’s clinical trial moots her Employee Retirement Income Security Act claim, and ERISA preempts her emotional distress claims, while the failure to allege the defendants receive federal aid dooms her Patient Protection and Affordable Care Act claim alleging discrimination, a federal judge in Florida said Feb. 17 in granting a motion to dismiss.

  • February 17, 2022

    Appellees: Insurers Ignore, Evade In Attempt To Challenge Coverage Determination

    DENVER — An insurer fails to provide the court with a sufficient record to make a ruling on appeal, and its arguments fail to grapple with the facts of the ruling under appeal, insureds tell the Tenth Circuit U.S. Court of Appeals in a Feb. 16 appellee brief.

  • February 15, 2022

    Members Assert Their ‘Detailed Allegations’ Put Defendant ‘On Adequate Notice’

    AKRON, Ohio — Members of health insurance plans on Feb. 4 defended their class complaint seeking a declaration that the plans “were and are illegal contracts” and a ruling that Liberty HealthShare Inc.’s CEOs or directors are personally liable upon finding Liberty an unauthorized and insolvent insurer under Virginia Code Annotated Section 38.2-215, arguing to an Ohio federal court that their complaint’s “detailed allegations” “clearly put” a defendant “on adequate notice of the charges brought against him.”

  • February 15, 2022

    Blue Cross Reinforces Objections To Discovery Order In Antitrust Coverage Suit

    KANSAS CITY, Kan. — Blue Cross Blue Shield of Kansas Inc. on Dec. 7 defended its objection to a Kansas federal magistrate judge’s “unprecedented” discovery order, refuting an opposition filed by an insurer that recently assumed an insolvent excess insurer’s responsibility for claims and defenses in an antitrust coverage dispute.

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