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Mealey's Health Care / ACA

  • August 30, 2018

    Judge Denies Judgment In Residential Treatment Insurance Denials Case

    SALT LAKE CITY — Any irregularities in a health insurer’s handling of two residential treatment claims do not warrant de novo review, and the record does not support the conclusion that the insurer abused its discretion in denying coverage for treatment two children received, a federal judge in Utah held Aug. 27 (Sandy Jo H., et al. v. Cigna Behavioral Health, et al., No. 17-110, D. Utah, 2018 U.S. Dist. LEXIS 146065).

  • August 30, 2018

    Judge: Medical Provider’s Anti-Assignment Arguments Contradict ERISA Precedent

    TRENTON, N.J. — A medical provider’s claim that an Employee Retirement Income Security Act plan’s anti-assignment provision involves only the insured’s right to assign benefits, not the power to do so, is contrary to district and circuit precedent, a federal judge in New Jersey said Aug. 27 (University Spine Center, et al. v. United Healthcare, No. 17-8575, D. N.J.).

  • August 30, 2018

    9th Circuit Reinstates California Abortion Disclosure Challenge

    SACRAMENTO, Calif. — A district court judge erred in concluding that crisis pregnancy centers (CPCs) were unlikely to prevail on their free speech claims challenging a California abortion-disclosure law and on remand should reconsider in light of more recent precedent, the Ninth Circuit U.S. Court of Appeals held Aug. 28 (A Woman’s Friend Pregnancy Resource Clinic, et al. Xavier Becerra, et al., No. 15-17517, 9th Cir., 2018 U.S. App. LEXIS 24327).

  • August 29, 2018

    Court Reinstates Class Action Involving Reasonable Medical Cost Determinations

    SEATTLE — Allegations that an insurer imposes a formulaic policy in determining what constitutes reasonable medical costs in a given geographic area form the basis of a Washington state consumer protection act claim, a state appellate court held Aug. 24 (Folweiler Chiropractic, et al. v. American Family Insurance Co., No. 76448-9-I, Wash. App., Div. 1, 2018 Wash. App. LEXIS 2029).

  • August 24, 2018

    Federal Judge Sanctions Insurer Over Incorrect Administrative Exhaustion Argument

    LOS ANGELES — Attorneys’ failure to investigate whether their health insurance client’s administrative appeals process applied to a contracted provider prior to arguing that the plaintiff failed to exhaust such remedies warrants imposing sanctions, a federal judge in California held Aug. 22 (Prime Healthcare Services Inc. v. Humana Insurance Co., et al., No. 16-1097, C.D. Calif.).

  • August 21, 2018

    11th Circuit Finds ACA Section 1557 Case Lacks Necessary Discrimination

    ATLANTA — Regardless of the standard applying in Patient Protection and Affordable Care Act (ACA) Section 1557 cases, the law at the very least requires evidence of discrimination an African-American dermatologist cannot produce in support of her allegation that a company selectively enforces its anti-assignment provision against women and minorities, a panel of the 11th Circuit U.S. Court of Appeals held Aug. 20 (W.A. Griffin v. Verizon Communications Inc., et al., No. 17-14761, 11th Cir., 2018 U.S. App. LEXIS 23146).

  • August 21, 2018

    Judge Rejects ACA Claims In Medicaid Case, But Enjoins Some Conduct

    RALEIGH, N.C. — Although a class’s Patient Protection and Affordable Care Act (ACA) discrimination claims against North Carolina officials fail, a federal judge said Aug. 9 that he would grant a modified injunction preventing the state from terminating Medicaid benefits (Marcia Hawkins, et al. v Mandy Cohen, et al., No. 17-581, E.D. N.C., 2018 U.S. Dist. LEXIS 134316).

  • August 21, 2018

    Judge Rejects Insurers’ Challenge To New York Risk Adjustment Program

    NEW YORK — Two insurers’ lawsuit challenging how New York’s risk adjustment program interacts with a similar Patient Protection and Affordable Care Act (ACA) program must be dismissed, a federal judge in the state held, finding Aug. 10 that while he had jurisdiction, the federal law did not preempt state attempts at regulating insurance markets (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 17-7694, S.D. N.Y., 2018 U.S. Dist. LEXIS 136380).

  • August 17, 2018

    Religious Employers Partially Granted Attorney Fees In ACA Dispute

    HANNIBAL, Mo. — Two religious employers who had challenged the contraceptive mandate included under the Patient Protection and Affordable Care Act (ACA) were awarded nearly $400,000 in attorney fees and expenses on Aug. 9 by a Missouri federal magistrate judge following the federal government’s decision to drop its opposition to their motion for a permanent injunction (Sharpe Holdings, Inc., et al. v. United States Department of Health and Human Services, et al., No. 12-92, E.D. Mo., 2018 U.S. Dist. LEXIS 134297).

  • August 14, 2018

    Claims Trimmed In Suit Over Denial Of Coverage For Outdoor Treatment Program

    SEATTLE — A Washington federal judge on Aug. 9 narrowed the claims in a class complaint filed by a teenager seeking reimbursement for an outdoor mental health treatment program, dismissing with prejudice a claim that the denial of reimbursement was improper under the Employee Retirement Income Security Act and claims seeking to enforce the plan and for equitable remedies, to the extent that they relied on a violation of the Affordable Care Act (ACA) (A.Z., et al. v. Regence Blueshield, et al., No. 17-1292, W.D. Wash., 2018 U.S. Dist. LEXIS 134669).

  • August 3, 2018

    Judge Increases Class Size, Settlement Fund In Autism Insurance Coverage Case

    BENTON, Ill. — A federal judge in Indiana on Aug. 1 said he would permit 62 additional plaintiffs into a class action alleging that an insurer denied applied behavioral analysis (ABA) autism treatments in violation of Indiana law and the Employee Retirement Income Security Act and noted that the defendant agreed to increase the settlement fund resolving the claims by $325,000 (W.P., et al. v. Anthem Insurance Companies Inc., No. 15-562, S.D. Ind.).

  • August 3, 2018

    Cities Sue Federal Officials, Claim Neglect In Administration Of ACA

    BALTIMORE — Having failed to pass legislation repealing the Patient Protection and Affordable Care Act (ACA), President Donald Trump now hopes to undermine it through neglect and sabotage, a collection of states and cities allege in an Aug. 2 complaint filed in Maryland federal court (Columbus, et al. v. Donald J. Trump, et al., No. 18-2364, D. Md.).

  • August 2, 2018

    Out-Of-Network Health Care Provider Isn’t Seeking ERISA Benefits, Judge Says

    TRENTON, N.J. — An out-of-network provider is not a beneficiary of an Employee Retirement Income Security Act plan, and because the plan includes an anti-assignment provision, it cannot sue to recover benefits under the law, a federal judge in New Jersey held July 31 in remanding the action (Advanced Orthopedics and Sports Medicine Institute v. Blue Cross Blue Shield of New Jersey, et al., No. 17-11807, D. N.J.).

  • August 1, 2018

    Judge Dismisses ACA, Civil Rights Claims From AIDS Drug Discrimination Case

    NASHVILLE, Tenn. — An insurer’s policy requiring that certain prescriptions be filled at specialty pharmacies appears to cover drugs disabled individuals would use and those used by others, dooming a man’s class action lawsuit alleging discrimination under the Patient Protection and Affordable Care Act (ACA), a federal judge in Tennessee said July 30 (John Doe, et al. v. Bluecross Blueshield of Tennessee Inc., No. 17-2793, W.D. Tenn.; 2018 U.S. Dist. LEXIS 126845).

  • July 31, 2018

    Insolvent Insurer Seeks Rehearing In Case Over ACA Risk-Corridor Payments

    WASHINGTON, D.C. — An insolvent health insurer on July 30 asks that the Federal Circuit U.S. Court of Appeals grant rehearing en banc, vacate its decision and enter judgment against the United States for billions in Patient Protection and Affordable Care Act (ACA) risk-corridor funds (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 17-1224, Fed. Cir.).

  • July 27, 2018

    States Say Association Health Plan Rule Violates ERISA, ACA

    WASHINGTON, D.C. — A U.S. Department of Labor final rule twists the Employee Retirement Income Security Act, permitting associations to offer non-Patient Protection and Affordable Care Act (ACA)-compliant health plans and “increases the risk of fraud and harm to consumers, requires states to redirect significant enforcement resources to curb those risks, and jeopardizes state efforts to protect their resident through stronger regulation.  The rule is unlawful and should be vacated,” numerous states complain in a July 26 lawsuit filed in District of Columbia federal court (New York, et al. v. U.S. Department of Labor, et al., No. 18-1747, D. D.C.).

  • July 26, 2018

    Father Claims Insurer Improperly Denied Autistic Son Behavioral Services

    NEW YORK — A health insurer denied necessary behavioral health treatments for a severely autistic individual despite plan language imposing no limitations or exclusions on such services, the patient’s father claims in a July 25 complaint in New York federal court (Harry DeMeo, M.D.,  et al. v. Oxford Health Plans [NY] Inc., et al., No. 18-5208, E.D. N.Y.).

  • July 24, 2018

    Judge Permits Potentially Duplicative ERISA Claims At Pleading Stage

    TRENTON, N.J. — It’s possible that a medical provider could prevail under contractual ERISA claims or on a count seeking other relief, and at this stage pleading both is permissible, a federal judge in New Jersey held July 20 (University Spine Center v. Aetna Inc., et al., No. 17-8747, D. N.J.).

  • July 23, 2018

    Judge Rules Deaf Man’s ACA Discrimination Claim May Proceed

    NEW ORLEANS — The Patient Protection and Affordable Care Act (ACA) incorporates the definition of discrimination and prerequisites for filing suit from other statutes that do not require exhaustion of administrative remedies in cases involving federal grantees, a federal judge in Louisiana said July 17 (Joseph Lockwood v. Our Lady of the Lake Hospital Inc., No. 17-509, M.D. La.).

  • July 23, 2018

    Judge Grants States’ Request To Dismiss ACA Cost-Sharing Cuts Case

    SAN FRANCISCO — A federal judge in California on July 18 dismissed a case challenging President Donald Trump’s revocation of Patient Protection and Affordable Care Act (ACA) cost-sharing measures after the plaintiffs informed him that the states managed to largely mitigate any damage from the move (California, et al. v. Donald J. Trump, et al., No. 17-5895, N.D. Calif., 2018 U.S. Dist. LEXIS 120200).