HOUSTON — A federal judge in Texas on Oct. 5 adopted a magistrate judge’s report recommending denying two motions for summary judgment in an Employee Retirement Income Security Act case, saying a surgery provider had not demonstrated entitlement to full compensation, but a health care plan had not shown that it properly calculated or explained reimbursement (Woodlands Outpatient Surgical Center, et al. v. America Bureau of Shipping Inc. Employee Benefit Plan, No. 17-1476, S.D. Texas, 2020 U.S. Dist. LEXIS 185882)
WASHINGTON, D.C. — A panel’s liability ruling limiting the government’s liability for Patient Protection and Affordable Care Act (ACA) risk-corridor underpayments requires rehearing to correct the decision’s unprecedented importation of contract mitigation principles, insurers tell a federal appeals court in an Oct. 16 amicus curiae brief (Maine Community Health Options v. United States, No. 19-2102, Fed. Cir.).
WASHINGTON, D.C. — In barring an emotional distress award in a Patient Protection and Affordable Care Act (ACA) discrimination case, the Fifth Circuit U.S. Court of Appeals created conflicts with precedent from other circuits, the Department of Justice’s position and at least four U.S. Supreme Court decisions, a deaf woman argues in an Oct. 14 reply in support of her petition for certiorari review (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).
NASSAU, N.Y. — An anti-assignment provision strips a health care provider of standing to bring an Employee Retirement Income Security Act claim, and a second claim for breach of contract fails regardless of whether it is based in state law or ERISA, a federal judge in New York said Sept. 28 in granting a motion to dismiss (Shuriz Hishmeh, et al. v. Horizon Blue Cross Blue Shield of New Jersey, No. 19-4727, E.D. N.Y., 2020 U.S. Dist. LEXIS 185515).
WASHINGTON, D.C. — The government may amend its answer to seek setoffs against risk-corridor liabilities it owes to largely insolvent insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor, a federal judge in the U.S. Court of Federal Claims said Sept. 30 in finding that amendment would be neither untimely nor prejudicial (Health Republic Insurance Co. v. United States, No. 16-259C, Fed. Clms., 2020 U.S. Claims LEXIS 1898).
NEW ORLEANS — The Fifth Circuit U.S. Circuit Court of Appeals on Oct. 15 vacated rulings dismissing a pro se plaintiff’s claims for prospective and retroactive relief of various provisions of the Patient Protection and Affordable Care Act (ACA), saying various changes in the law required a more thorough analysis (John J. Dierlam v. Donald J. Trump, et al., No. 18-20440, 5th Cir., 2020 U.S. App. LEXIS 32632).
CINCINNATI — The majority of the Sixth Circuit U.S. Court of Appeals on Oct. 14 reversed a district court’s ruling that a health insurance administrator’s decision to make all dialysis companies out-of-network providers does not violate the Medicare Secondary Payor Act (MSPA) and found that the provider’s assignment of rights form clearly conferred a right on the provider to bring a claim for unpaid benefits under the Employee Retirement Income Security Act (DaVita Inc., et al. v. Marietta Memorial Hospital Employee Health Benefit Plan, et al., No. 19-4039, 6th Cir., 2020 U.S. App. LEXIS 32398).
WASHINGTON, D.C. — The Patient Protection and Affordable Care Act (ACA) does not permit the imposition of emotional distress damages in a case where a deaf and blind woman claims that she was denied an interpreter, a health care provider told the U.S. Supreme Court in a Sept. 24 opposition to certiorari (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).
SEATTLE — A motion seeking dismissal did not produce a merits determination inconsistent with arbitration rights, but rather simply a conclusion that plaintiffs adequately pleaded claims involving a trio of defendants who allegedly sold health care sharing ministry plans under the Patient Protection and Affordable Care Act (ACA), a federal judge in Washington said Oct. 7, vacating an earlier ruling and granting a motion to compel arbitration (Gerald Jackson, et al. v. The Aliera Companies Inc., et al., No. 19-1281, W.D. Wash., 2020 U.S. Dist. LEXIS 185339).
BOSTON — In an Oct. 7 amicus curiae brief, the U.S. Department of Labor contends that a district court erred in finding that health insurance coverage is excluded for nonrestorative speech therapy because the appellant, a 5-year-old who suffers from autism spectrum disorder, and his parents are authorized to bring a claim for the denied benefits under the Employee Retirement Income Security Act (N.R., et al. v. Raytheon Co., et al., No. 20-1639, 1st Cir.).
SALT LAKE CITY — The distinct nature of Parity Act claims over the allegedly improper denial of insurance coverage for mental health treatments requires discovery exceeding the administrative record to which Employee Retirement Income Security Act cases are generally limited, a federal judge in Utah said Sept. 30 (David S., et al. v. United Healthcare Insurance Co., No. 18-803, D. Utah, 2020 U.S. Dist. LEXIS 182120).
SACRAMENTO, Calif. — A purported anti-assignment provision falls outside governing Employee Retirement Income Security Act health insurance plan documents, but even if applicable, the language would not support excluding assignment or payment to a provider, a divided Ninth Circuit U.S. Circuit Court of Appeals said Oct. 2 in affirming judgment in favor of a hospital (Martin Luther King Jr. Community Hospital v. Community Insurance Co., et al., No. 19-55052, 9th Cir., 2020 U.S. App. LEXIS 31441).
SAN FRANCISCO — A surgery provider adequately alleges that an insurer should be estopped from untimely raising an anti-assignment provision and demonstrates entitlement to benefits under an insurance health care plan, a federal judge in California said Sept. 25 in extending a Ninth Circuit U.S. Circuit Court of Appeals ruling and denying dismissal (California Spine and Neurosurgery Institute v. Blue Cross of California, No. 18-4777, N.D. Calif.).
LOS ANGELES — A breach of contract claim accrued when an insurer denied coverage, putting the provider's suit outside the four-year window for such claims, a federal judge in California said in dismissing the claim Sept. 29 (IV Solutions Inc., et al. v. Empire HealthChoice Assurance Inc., et al., No. 17-5616, C.D. Calif., 2020 U.S. Dist. LEXIS 179444).
WASHINGTON, D.C. — A ruling freeing the government from liability for mandated Patient Protection and Affordable Care Act (ACA) cost-sharing payments where insurers raised premiums unnecessarily imputes contract concepts into what should be a straightforward application of statutory law, an insurer says in a Sept. 28 petition for rehearing with a federal circuit court, warning of the "enormous" stakes (Maine Community Health Options v. United States, No. 19-2102, Fed. Cir.).
SALT LAKE CITY — Two individuals adequately allege that their insurer imposes coverage standards on mental health services that it does not impose on analogous services in the medical and surgical setting, and nothing precludes them from bringing their Mental Health Parity and Addiction Equity Act claim in addition to an Employee Retirement Income Security Act action, a federal judge in Utah said Sept. 24 (Denise M. v. Cigna Health and Life Insurance Co., et al., No. 19-764, D. Utah, 2020 U.S. Dist. LEXIS 176154).
NEW YORK — A single Employee Retirement Income Security Act claim challenging a health insurer's reimbursement practices is all that remains of a plastic surgeon's case after a judge concluded Sept. 23 that a lack of monopoly power, claims duplication and preemption call for largely granting the company's motion to dismiss (Michael E. Jones, et al. v. Aetna Inc., et al., No. 19-9683, S.D. N.Y.).
SACRAMENTO, Calif. — California Gov. Gavin Newson on Sept. 25 signed legislation designed to overhaul and modernize the state's mental health coverage law by imposing more comprehensive mental health coverage requirements on insurers while placing limits on the ability of insurers to avoid coverage.
CHICAGO — Women allegedly denied coverage for lactation services mandated by the Patient Protection and Affordable Care Act (ACA) fail to adequately allege that their insurer had an actual policy of denying the claims or imposing cost-sharing, a federal judge in Illinois said Sept. 24 in declining to certify the class (Laura Briscoe, et al. v. Health Care Service Corporation, et al., No. 1:16-cv-10294, N.D. Ill., 2020 U.S. Dist. LEXIS 175618).
WASHINGTON, D.C. — Recent research into short-term, limited-duration insurance (STLDI) plans differs significantly enough from Congressional Budget Office (CBO) standards that it does not require reevaluating whether most enrollees in such plans are receiving actual insurance coverage, the CBO said in a Sept. 25 report.