LAS CRUCES, N.M. — An air transport’s challenge to New Mexico’s law precluding balance billing stems from a ruling in a review involving an insured and insurer and is not properly before the court, a federal judge in New Mexico said Dec. 10 (Phi Air Medical LLC v. New Mexico Office of Superintendent of Insurance, et al., No. 18-382, D. N.M., 2018 U.S. Dist. LEXIS 207895).
NEW YORK — Health insurers due money under the Patient Protection and Affordable Care Act (ACA) risk-adjustment program and New York state faced off in Dec. 10 simultaneous briefing in the Second Circuit U.S. Court of Appeals over whether New York could lay claim to some of those proceeds under its own risk-adjustment program (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).
BOSTON — A health insurance plan’s exclusion for custodial care unambiguously includes the wilderness therapy treatments at the heart of three plaintiffs’ ERISA suit, a federal judge in Massachusetts said Dec. 6 (David Cotton, et al. v. Blue Cross and Blue Shield of Massachusetts HMO Blue Inc., et al., No. 16-12176, D. Mass., 2018 U.S. Dist. LEXIS 205869).
BILLINGS, Mont. — A woman’s claim seeking to recover additional payments from her health insurer for air transport is timely under the ambiguous terms of the plan, she has standing under the Employee Retirement Income Security Act and her claims support a breach of fiduciary duty claim, a federal judge in Montana held Dec. 3 in largely permitting her suit to proceed (Jennifer Tawater v. Health Care Services Corp., et al., No. 18-47, D. Mont., 2018 U.S. Dist. LEXIS 204309).
TRENTON, N.J. — An insured adequately alleges entitlement to additional coverage for out-of-network care under his plan’s emergency services provision, but not how his insurer’s payment would violate that provision, a New Jersey federal judge said Nov. 30 (Clifford Robinson v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J., 2018 U.S. Dist. LEXIS 202887).
SAN DIEGO — Allegations that a man paid higher prices for generic drugs as a result of a pharmacy’s two-tiered pricing scheme give him standing and adequately allege a California unfair competition law (UCL) violation for unfair conduct, but several of his claims appear untimely and must be dismissed, a federal judge in California held Nov. 20 (Robert Josten, et al. v. Rite Aid Corp., No. 18-152, S.D. Calif., 2018 U.S. Dist. LEXIS 198124).
YAKIMA, Wash. — A woman’s class action claiming that her health care insurer misrepresented the coverage and provider network its policy provided does not ask the court to review agency-established premiums and adequately alleges breach of contract and violation of state consumer protection law, a federal judge in Washington state held Nov. 21 (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash., 2018 U.S. Dist. LEXIS 198773).
TRENTON, N.J. — A medical provider’s pursuit of reimbursement stands or falls on the strength of its state law causes of action and belongs in state court, a federal judge in New Jersey held Nov. 26 in adopting a recommendation that the case be remanded (East Coast Advanced Plastic Surgery v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 18-7718, D. N.J., 2018 U.S. Dist. LEXIS 199891).
TRENTON, N.J. — The conclusion that not all of an insurer’s overpayment letters to medical providers constituted a demand for payment or adverse benefit denial made class certification of plaintiffs’ Employee Retirement Income Security Act claims improper, a federal judge in New Jersey held in denying reconsideration on Nov. 26 (Association of New Jersey Chiropractors, et al. v. Aetna Inc., et al., TRI3 Enterprises LLC, et al. v. Aetna Inc., et al., Nos. 09-3761, 11-3921, D. N.J., 2018 U.S. Dist. LEXIS 199431).
NEW YORK — A former Dave & Buster’s Inc. employee accusing the chain of violating the Employee Retirement Income Security Act by reducing the hours of its work force in 2013 to avoid the costs associated with providing health insurance to its full-time employees in compliance with the Patient Protection and Affordable Care Act (ACA) on Nov. 20 filed a second motion in New York federal court for approval of a $7.4 million offer to resolve the suit (Maria De Lourdes Parra Marin v. Dave & Buster’s, Inc., et al., No. 15-3608, S.D. N.Y.).
HARRISBURG, Pa. — Citing rules newly issued two weeks ago, the Third Circuit U.S. Court of Appeals on Nov. 20 stayed a case challenging the expansion of moral and religious exemptions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate (Commonwealth of Pennsylvania, et al. v. Donald J. Trump, et al., Nos. 17-3752, 18-1253, 3rd Cir.).
WASHINGTON, D.C. — An insurer and employer on Nov. 19 waived their right to respond to a U.S. Supreme Court petition alleging that they discriminated against African-Americans and women providers under the Patient Protection and Affordable Care Act (ACA) by selectively enforcing anti-assignment provisions (W.A. Griffin v. Verizon Communications Inc., et al., No. 18-523, U.S. Sup.).
TRENTON, N.J. — A valid anti-assignment provision dooms providers’ Employee Retirement Income Security Act claims, while the insured presents nothing suggesting that her insurer need to pay the providers more than it did, a federal judge in New Jersey held Oct. 31 (Atlantic Plastic & Hand Surgery, PA, et al. v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4599, D. N.J.).
PHILADELPHIA — Under recent Third Circuit precedent, a valid anti-assignment provision strips providers of standing to pursue ERISA claims, a federal judge in Pennsylvania held Oct. 25 (Howard Bloom, et al. v. Independence Blue Cross, et al., No. 14-2582, E.D. Pa., 2018 U.S. Dist. LEXIS 183023).
WASHINGTON, D.C. — Neither plaintiffs nor defendants got their wish in a federal judge’s Nov. 12 minute order setting simultaneous and slightly expedited briefing of a challenge to a Patient Protection and Affordable Care Act (ACA) rule expanding the availability of short-term, limited coverage health plans (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).
LOS ANGELES — An insurer never contests claims arising from its underpayment for medical services, and its unilateral and unlawful decision to simply reduce a bill by an amount it claimed it was owed evidences an “overt disregard” for the business and supports a punitive damages claim, a California out-of-network provider says Nov. 9 in a federal court in California (California Spine and Neurosurgery Institute v. Aetna Life Insurance Co., et al., No. 18-6829, C.D. Calif.).
NEW YORK — New York may not confiscate tens of millions of dollars under its risk-adjustment program while two insurers appeal the program’s interaction with a similar Patient Protection and Affordable Care Act (ACA) provision, the Second Circuit U.S. Court of Appeals held Oct. 10 in granting a temporary injunction (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).
TRENTON, N.J. — A dispute over an insurer’s failure to fully pay a provider’s bill heads back to state court, after a federal judge on Nov. 9 partially adopted a report and recommendation finding that an anti-assignment provision precluded the provider from filing an ERISA action and prevented preemption (Tzvi Small v. Blue Cross Blue Shield of Michigan, et al., No. 18-11601, D. N.J., 2018 U.S. Dist. LEXIS 192415).
WASHINGTON, D.C. — New rules allowing associations to offer large group market health insurance plans largely ungoverned by the Patient Protection and Affordable Care Act (ACA)’s protections would help provide quality, affordable health insurance to an underserved market and are within an agency’s power, two business interests and a handful of states told a federal court in the District of Columbia on Nov. 7 (New York, et al. v. U.S. Department of Labor, et al., No. 18-1747, D. D.C.).
WASHINGTON, D.C. — Employers with moral and religious objections to providing insurance coverage for contraceptives required by the Patient Protection and Affordable Care Act (ACA) would be exempts from the law’s mandate under a pair of rules announced Nov. 7.