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Mealey's Health Care / ACA

  • 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).

  • July 19, 2018

    Judge: Benefits Assignment Can’t Save Provider’s Suit Against Health Insurer

    TRENTON, N.J. — It is impossible to tell from an illegible assignment of benefits just what powers an insured was granting his provider, and nothing in the complaint suggests that the assignment satisfied the requirements stated in the summary plan description, a federal judge in New Jersey held in dismissing an action on June 28 (University Spine Center, et al. v. United Healthcare, No. 17-8789, D. N.J., 2018 U.S. Dist. LEXIS 107828).

  • July 19, 2018

    Judge Grants Judgment To Insurer In Provider’s Denial Of Payment Suit

    TRENTON, N.J. — A health care insurance contract’s anti-assignment provision clearly and unambiguously prevented an insured from transferring her rights under the plan to her provider, a federal judge in New Jersey held June 29 (Rahul Shah, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 16-5946, D. N.J., 2018 U.S. Dist. LEXIS 109703).

  • July 19, 2018

    Judge Finds Claims Insurer, Employer Promised Dental Coverage Don’t Invoke ERISA

    HOUSTON — Breach of contract, negligent misrepresentation and fraud claims arising from an insurer and employer’s alleged statements indicating that a plan covered 100 percent of a dental procedure do not meet the factors for Employee Retirement Income Security Act removal under Aetna Health Inc. v. Davila, a Texas federal judge held June 25 in remanding the case (Texas Oral and Facial Surgery PA v. United Healthcare Dental Inc., et al., No. 18-0944, S.D. Texas).

  • July 19, 2018

    Health Insurer, Employer Say Providers, Not Patient, Authored ERISA Complaint

    TRENTON, N.J. — An amended complaint largely “regurgitates” allegations previously rejected as insufficient and was likely authored not by the plaintiff, but the health care providers dismissed from the case, a health insurer and employer argue in a July 16 brief seeking dismissal of ERISA claims as well as attorney fees (Clifford Robinson v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J.).

  • July 18, 2018

    Health Insurer UCL Claims Lack Specifics; Anti-Assignment Provision Bars Action

    SANTA ANA, Calif. — Anti-assignment provisions preclude a plastic surgery center’s suit challenging denial of health insurance claims, and the provider lacks the necessary specificity to plead California unfair competition law (UCL) claims, an insurer says July 16 in asking a California federal judge to dismiss the claims (California Surgical Institute Inc. v. Aetna Life And Casualty [Bermuda] Ltd., et al., No. 17-310, C.D. Calif.).

  • July 18, 2018

    Judge: Air Transport’s Lien Against Insurance Recovery Keeps Some Claims Alive

    ST. LOUIS — A membership-based emergency air transport’s contract is ambiguous as to whether it may recover only from health insurance or is entitled to recovery from broader insurance as well, and its apparent attempts at collecting the proceeds of a tort settlement are enough to permit some breach of contract and injunctive relief claims against it by one of its members alive, a federal judge in Missouri held July 16 (Doris Ergle Lindsey Pratt v. Air Evac Lifeteam, et al., No. 17-3097, W.D. Mo., 2018 U.S. Dist. LEXIS 117854).

  • July 18, 2018

    Class Drops ACA Claims From Action Alleging Insurance ‘Bait-And-Switch’

    YAKIMA, Wash. — Plaintiffs claiming that insurers engaged in a bait-and-switch scheme in which they advertised Affordable Care Act (ACA)-compliant plans but provided only “woefully little coverage” after enrollment may amend their complaint to drop those and other claims, a federal judge in Washington said July 17 while striking pending motions to dismiss the case (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash.).

  • July 16, 2018

    Judge Won’t Expand Record To Evidence Outside ERISA Health Insurance Review

    BOSTON — Medical records and communications predating a woman’s bulimia treatments and evidence of her long struggle with the disease were not part of an insurer’s process in denying her coverage and cannot be made part of the judicial record, a federal judge in Massachusetts said July 13 in denying a motion to expand the record in an ERISA case (Addie Fisher v. Harvard Pilgrim Health Care of New England Inc., No. 17-11232, D. Mass., 2018 U.S. Dist. LEXIS 116751).

  • July 16, 2018

    Judge: Recent 3rd Circuit ERISA Case Affirms Validity Of Anti-Assignment Clause

    CAMDEN, N.J. — Third Circuit U.S. Court of Appeals precedent recently confirmed the validity of anti-assignment clauses in the Employee Retirement Income Security Act setting, and a health insurer’s interactions with a provider during the administrative appeals process did not waive the defense, a federal judge in New Jersey held July 13 (Rahul Shah, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 17-166, D. N.J.).

  • July 12, 2018

    Hospital Group Says Medicare Exhaustion Split Is ‘Real,’ Requires Review

    WASHINGTON, D.C. — A Medicare Advantage insurer cherry-picks quotes and misrepresents precedent in an attempt to avoid the very real conflict regarding whether noncontracted providers must exhaust of administrative remedies prior to filing suit, a hospital group tells the U.S. Supreme Court in a July 10 brief (Atlanta Medical Center Inc., et al. v. Care Improvement Plus South Central Insurance Co., No. 17-1283, U.S. Sup.).

  • July 11, 2018

    Insurance Parties Debate Discrimination In Gender Dysphoria Surgery Exclusion

    MADISON, Wis. — A Wisconsin federal judge received reply briefs July 9, laying before him the issue of whether a health insurance plan’s exclusion on cosmetic vaginoplasties discriminates against transgendered individuals and violates the Patient Protection and Affordable Care Act (ACA) and the U.S. Constitution (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • July 10, 2018

    Florida Law Claim Survives Dismissal In Hospital-Insurer Spat

    JACKSONVILLE, Fla. — A federal judge in Florida on July 5 adopted a magistrate judge’s report, dismissing breach of contract claims against an insurer brought by a hospital group but saying a state law claim survived (Southern Baptist Hospital of Florida Inc., et al. v. Celtic Insurance Co., etc., No. 17-1214, M.D. Fla.)

  • July 5, 2018

    Judge Won’t Reconsider Remand Of Liquidation Action Featuring ACA Insurer

    CHICAGO — A liquidation procedure involving a Patient Protection and Affordable Care Act (ACA) nonprofit health insurer is exactly the type of proceeding where Congress defers to states, a federal judge in Illinois held July 2 in once again finding that the case should be remanded (Melissa Dowling v. United States Department of Health and Human Services, No. 17-494, N.D. Ill., 2018 U.S. Dist. LEXIS 110554).

  • July 2, 2018

    Some Named Class Members Prevail On Judgment Motions In ACA Lactation Case

    SAN FRANCISCO — The Patient Protection and Affordable Care Act (ACA) recognizes lactation support services as preventive care and does not carve out situations where women receive the services in response to symptoms, a federal judge in California held in partially granting judgment to named class members on ACA and ERISA claims June 27 (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).

  • June 26, 2018

    Birth Control Defendants Tell 9th Circuit Injury Lacking In ACA Rules Case

    SAN FRANCISCO — States have not shown that federal regulations expanding moral and religious exemptions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate would result in any women turning to them for coverage or that the rules would impact state budgets in any way, two intervenors and the federal defendants told the Ninth Circuit U.S. Court of Appeals on June 11 in arguing that the plaintiffs lack standing (California, et al. v. Alex M. Azar II, et al., Nos. 18-15144, 18-15166, 18-15255, 9th Cir.).

  • June 26, 2018

    Supreme Court Sees Challenge To Abortion Disclosure Law As Likely To Prevail

    WASHINGTON, D.C. — Crisis pregnancy centers are likely to prevail on the merits of their challenge to a California law imposing certain disclosures on similar providers, a 5-4 majority of the U.S. Supreme Court held June 26 (NIFLA, et al. v. Xavier Becerra, et al., No. 16-1140, U.S. Sup.).

  • June 25, 2018

    Medicare Exhaustion Ruling Properly Diagnosed Law, Insurer Tells Supreme Court

    WASHINGTON, D.C. — An appeals court properly recognized the difference between contracted Medicare providers and non-contracted providers in requiring exhaustion of administrative remedies prior to filing suit, an insurer told the U.S. Supreme Court June 22 (Atlanta Medical Center Inc., et al. v. Care Improvement Plus South Central Insurance Co., No. 17-1283, U.S. Sup.).

  • June 25, 2018

    Medicare Doesn’t Preempt Breach Of Contract Claims By Hospital Group, Judge Says

    LOS ANGELES — Medicare doesn’t preempt a hospital group’s breach of contract action alleging that an insurer downcoded claims in an effort to underpay on bills, a federal judge in California held June 22 (Prime Healthcare Services Inc. v. Humana Insurance Co., et al., No. 16-1097, C.D. Calif.).

  • June 20, 2018

    Insurer Says ERISA Preempts Hospital Group’s Case; Facts Don’t Support Claims

    SALT LAKE CITY — The Employee Retirement Income Security Act preempts a hospital group’s claims alleging underpayment of medical bills, but the claims would fail in any case because they involve insurer-insured rights and cannot be assigned to third parties, an insurer tells a federal judge in Utah in a June 15 memo (IHC Health Services Inc., et al. v. Blue Cross and Blue Shield of Texas Inc., No. 18-277, D. Utah).