Mealey's Health Care / ACA

  • June 08, 2020

    Class Allegations Struck From Proton Beam Treatment Case

    CHICAGO — An insured whose proton beam radiation therapy (PBRT) treatment for brain cancer was rejected by her Employee Retirement Income Security Act plan and the plan administrator may proceed with claims for benefits and attorney fees and costs against both defendants and a breach of fiduciary duty claim against the administrator only, a federal judge in Illinois ruled June 1, dismissing the breach claim against the plan and striking the complaint’s class claims partially based on the “fail-safe” definition (Brittany Day, et al. v. Humana Insurance Company, et al., No. 19-3141, N.D. Ill., 2020 U.S. Dist. LEXIS 95211).

  • June 08, 2020

    Judge Finds Class’s ERISA Document Case Lacking

    SEATTLE — Documents a class of plaintiffs seek from an insurance plan administrator lack sufficient impact on subscriber rights to warrant imposing a duty to disclose under the Employee Retirement Income Security Act, a federal judge in Washington said June 5 (Justin Penwell, et al. v. Providence Health & Services, No. 19-1786, W.D. Wash., 2020 U.S. Dist. LEXIS 99277).

  • June 05, 2020

    Judge:  Lung Transplant Claims Subject To Medicare Exhaustion, Even Where Futile

    LOS ANGELES — Before bringing any suit alleging that a Medicaid Advantage insurer improperly denied preauthorization for lung transplant consultations, a widow must exhaust administrative options, even if that review is futile given the insured’s death, and the claims are preempted by federal law, a federal judge in California said June 2 in granting the defendant summary judgment (Naomi J. Aylward, et al. v. SelectHealth Inc., et al., No. 18-494, S.D. Calif., 2020 U.S. Dist. LEXIS 96675).

  • June 02, 2020

    ‘Procedural Irregularities’ Lead To Reversal Of Mental Health Coverage Case

    SALT LAKE CITY — The “serious procedural irregularities” infecting an adverse benefits determination, including the failure to consider substance abuse issues in any way and a conclusory explanation of the denial, warrant reviewing the decision de novoand reversing on the grounds that the decision was arbitrary and capricious, a federal judge in Utah said May 29 (Raymond M., et al. v. Beacon Health Options Inc., et al., No. 18-48, D. Utah, 2020 U.S. Dist. LEXIS 94615).

  • June 01, 2020

    Judge: Allegations Suggest Defendant Is Insurer, Not Exempt From ACA

    SEATTLE — A class action sufficiently alleges that a trio of defendants provided health insurance governed by the Patient Protection and Affordable Care Act (ACA) and Washington law and not an exempt Health Care Sharing Ministry, a federal judge in Washington said May 26 (Gerald Jackson, et al. v. The Aliera Companies Inc., et al., No. 19-1281, W.D. Wash., 2020 U.S. Dist. LEXIS 91699).

  • June 01, 2020

    Judge: Underlying Statute’s Limitation Period Bars ACA Discrimination Case

    NEW ORLEANS — The one-year statute of limitation imposed by the Rehabilitation Act on which a deaf woman’s Patient Protection and Affordable Care Act (ACA) claim relies bars her case, a federal judge in Louisiana said May 27 (Renee Solis V. Our Lady of the Lake Ascension Community Hospital Inc., No. 18-56, M.D. La., 2020 U.S. Dist. LEXIS 92297).

  • June 01, 2020

    Colorado Court: ‘All Charges’ Contract Puts Patient On Hook For Billed Balance

    DENVER — A health services agreement (HSA) requiring a patient to pay “all charges” unambiguously includes an out-of-network hospital’s chargemaster rates and leaves her liable for the unpaid balance, a Colorado appeals court held May 28 (Centura Health Corp., et al. v. Lisa Melody French, No. 2020COA85, Colo. App., 2020 Colo. App. LEXIS 1045).

  • May 28, 2020

    Judge:  Allegedly Quick ‘Medically Necessary’ Call Supports Parity Act Claims

    SALT LAKE CITY — Parity Act claims involving residential mental health treatments will proceed after a federal judge in Utah on May 26 found that the plaintiffs satisfy each of the three prongs often used to analyze such claims (Nancy S., et al. v. Anthem Blue Cross and Blue Shield, No. 19-231, D. Utah).

  • May 28, 2020

    HHS Appeals Ruling Allowing Appeal Of Denial Of Medicare Coverage For Hospital Stays

    HARTFORD, Conn. — The secretary of Health and Human Services on May 22 notified a federal court in Connecticut that he plans to appeal to the Second Circuit U.S. Court of Appeals the district court’s March 24 ruling allowing a portion of a class of Medicare beneficiaries placed on observation status after being admitted to the hospital as inpatients to appeal their denial of coverage (Christina Alexander, et al. v. Alex M. Azar II, No. 11-1703, D. Conn.).

  • May 22, 2020

    Judge:  Deaf Woman’s ACA Discrimination Claim Survives Judgment

    DENVER — A deaf woman’s discrimination claims against a health care provider and its owners under the Patient Protection and Affordable Care Act (ACA) and Rehabilitation Act survive defendants’ motion for judgment, but only a jury can decide whether they violated her rights by failing to provide an interpreter, a federal judge in Colorado said May 20 in denying her dueling motion (Cynthia Mullen, et al. v. South Denver Rehabilitation, et al., No. 18-1552, D. Colo.).

  • May 20, 2020

    Plan To High Court:  No Conflict Over 5th Circuit Denial Of Fee Award

    WASHINGTON, D.C. — A health plan administrator argues in a May 15 opposition brief to the U.S. Supreme Court that a recent denial of an attorney fees award by the Fifth U.S. Circuit Court of Appeals to a plan participant who, in an earlier appeal, won a procedural victory, did not create confusion courts among courts handling cases under the Employee Retirement Income Security Act (Ariana M. v. Humana Health Plan of Texas, Inc., No. 19-980, U.S. Sup.).

  • May 19, 2020

    5th Circuit Vacates, Sends Back ERISA Dispute Over Eating Disorder Treatment

    NEW ORLEANS —The Fifth U.S. Circuit Court of Appeals ruled May 14 that an issue of fact should have precluded summary judgment to Humana Health Plan Inc. in an Employee Retirement Income Security Act dispute over the insurer’s partial denial of coverage to a woman who sought hospitalization to treat an eating disorder (Katherine P. v. Humana Health Plan, Inc., No. 19-50276, 5th Cir.; 2020 U.S. App. LEXIS 15465).

  • May 18, 2020

    Insurer-Provider Arbitration Agreement Can’t Extend Into Perpetuity, Judge Says

    MIAMI — A health insurer’s portrayal of an arbitration agreement with a provider as surviving the contract’s termination and existing into perpetuity “borders on frivolous,” a state judge in Florida said May 1 in declining to compel arbitration (Kidz Medical Services Inc. v. UnitedHealthcare of Florida Inc., et al., No. 2019-0234560-CA-01, Fla. Cir., Miami-Dade Co., 2020 Fla. Cir. LEXIS 390).

  • May 14, 2020

    Expert’s Sign Language Testimony Allowed In ACA Discrimination Action

    BATON ROUGE, La. — An expert’s opinions on the differences between communicating by talking and doing so by sign language in a Patient Protection and Affordable Care Act (ACA) suit asserting that a hospital discriminated against a deaf woman by not offering her a sign language interpreter will assist jurors and should not be excluded, a Louisiana federal judge held May 13 (Katrina Rivers Labouliere v. Our Lady of the Lake Hospital, Inc., No. 16-785, M.D. La., 2020 U.S. Dist. LEXIS 84024).

  • May 14, 2020

    Declaratory Action Against Air Transport Companies’ Billing Proceeds, Judge Says

    DENVER — A class of insured individuals pursuing an action alleging that air transport companies charged them exorbitant fees may pursue a declaratory order that no contract exists between the parties, but their injunctive and nondeclaratory relief claims fail, a federal judge said May 8 while denying a motion to strike class claims (Jeremey Lee Scarlett, et al. v. Air Methods Corp., et al., Nos. 17-485, 17-502, 17-509, 17-667, 17-791, 17-1771, 19-1951, D. Colo. 2020 U.S. Dist. LEXIS 81382).

  • May 14, 2020

    Individual Issues Doom Class Alleging Inferior Provider Network, Judge Says

    YAKIMA, Wash. — A plaintiff credibly alleges that her insurer overstated its provider network, causing her to spend money on out-of-network care, but the individualized issues required for a remedy and the existence of superior methods of seeking relief doom the class, a federal judge in Washington said May 12 (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash., 2020 U.S. Dist. LEXIS 83642).

  • May 12, 2020

    Judge Allows Provider’s Reimbursement Suit Involving Federal Health Plan

    WASHINGTON, D.C. — Nothing prevents a dialysis provider from pursuing reimbursement claims under a federal health insurance policy as an assignee, a federal judge in the District of Columbia said May 8 (RAI Care Centers of Maryland I v. Office of Personnel Management, No. 18-3151, D. D.C., 2020 U.S. Dist. LEXIS 81431).

  • May 11, 2020

    Consolidated Complaint Says Insurers Failed To Pay For Mental Health Treatments

    LOS ANGELES — A facility provided medically necessary treatments to insureds with plans covering mental health and substance abuse treatments but was not reimbursed for the care, a plaintiff alleges in a May 7 consolidated amended complaint (ABC Services Group Inc v. Health Net of California Inc., et al., No. 19-243, C.D. Calif.).

  • May 08, 2020

    Judge Denies New Trial After Jury Finds For Hospital In ACA Discrimination Case

    NEW YORK — A deaf woman’s testimony at trial that she requested American Sign Language (ASL) interpreters does not entitled her to judgment, and nothing in a trial over alleged discrimination under the Patient Protection and Affordable Care Act (ACA) and other laws warrants granting a new one, a federal judge in New York said March 26 (Lizzette Vega-Ruiz v. Montefiore Medical Center, No. 17-1804, S.D. N.Y., 2020 U.S. Dist. LEXIS 53285).

  • May 08, 2020

    4th Circuit Confronts Title X Case Over Funding, Abortion

    BALTIMORE — The ethical and financial implications of a rule requiring strict separation of medical and abortion services for Title X funding recipients featured heavily in oral arguments before the Fourth Circuit U.S. Court of Appeals on May 7 (Mayor and City Council of Baltimore v. Alex M. Azar II, et al., Nos. 19-1614, 20-1215, 4th Cir.).

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