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Mealey's Health Care / ACA

  • November 7, 2018

    Divided Court Denies Insurers Rehearing In ACA Risk-Corridor Case

    WASHINGTON, D.C. — With two judges dissenting, a federal appeals court on Nov. 6 declined to rehear health care insurers’ case claiming that the government owes them billions of dollars in Patient Protection and Affordable Care Act (ACA) risk-corridor funds (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 17-1224, Moda Health Plan Inc. v. United States, No. 17-1994, Blue Cross and Blue Shield of North Carolina v. United States, No. 17-2154, Maine Community Health Options v. United States, No. 17-2395, Fed. Cir., 2018 U.S. App. LEXIS 31395).

  • November 7, 2018

    Health Care Allegations Don’t Rise To Level Of Discrimination, Judge Says

    SPOKANE, Wash. — While a deaf plaintiff need not plead the specific medical information she left uncommunicated as a result of a hospital’s alleged failure to provide an in-person interpreter, her “vague” and potentially “hyperbolic” allegations are insufficient to establish discrimination under the Patient Protection and Affordable Care Act (ACA) and other federal statutes, a federal judge in Washington state held Nov. 2 (Alissa Juech v. Children’s Hospital and Health System Inc., et al., No. 15-1482, E.D. Wash., 2018 U.S. Dist. LEXIS 188000).

  • November 6, 2018

    Federal Judge Enjoins Insurer At Heart Of ‘Massive’ ACA Insurance Scheme

    MIAMI — A federal judge in Florida issued an injunction and placed a health insurer into temporary receivership after the Federal Trade Commission alleged that the company sold limited benefit and medical discount memberships it misrepresented as providing comprehensive coverage under the Patient Protection and Affordable Care Act (ACA), according to a Nov. 2 release from the agency (Federal Trade Commission v. Simple Health Plans LLC, et al., No. 18-62593, S.D. Fla.).

  • November 2, 2018

    Judge: Insurer Can’t Escape Utah As Venue For Mental Health Coverage Case

    SALT LAKE CITY — A health insurer’s decision to have its insureds file claims and appeals with a Utah address provides sufficient basis for bringing a suit claiming that it improperly denied coverage for residential adolescent mental health treatment, a federal judge held Oct. 24 (D.K., et al. v. United Behavioral Health, et al., No. 17-1328, D. Utah, 2018 U.S. Dist. LEXIS 183341).

  • November 2, 2018

    With Trial Looming, Judge Continues Depression Treatment Insurance Coverage Case

    BRIDGEPORT, Conn. — Parties may explore a settlement before engaging in trial preparation, a federal judge in Connecticut said Oct. 16 in a docket entry granting a joint motion to continue only days after a summary judgment ruling allowed claims challenging denial of coverage for transcranial magnetic stimulation therapy (Christopher Meidl, et al. v. Aetna, Inc., et al., No. 15-1319, D. Conn.).

  • October 31, 2018

    Judge Expands Distribution Period In Mental Health Coverage Settlement Case

    CHICAGO — A federal judge in Illinois on Oct. 26 modified a settlement agreement resolving claims that an insurer improperly denied coverage for residential mental health treatments, granting a 45-day extension for distribution of hundreds of thousands of dollars in remaining funds despite the lack of any language in the agreement envisioning such a move (Elizabeth A. Craft, et al. v. Health Care Service Corp., No. 14-5853, N.D. Ill., 2018 U.S. Dist. LEXIS 184108).

  • October 30, 2018

    Judge Rejects UCL Claim For Insurer’s Alleged Failure To Pay For Services

    SAN FRANCISCO — After finding that claims for violation of California’s unfair competition law (UCL) in relation to an insurer’s alleged failure to pay hospitals for noncontracted services could not be based on the improper application of the California Code of Regulations, a California federal judge on Oct. 26 granted the insurer’s motion for partial summary judgment on the UCL claims (NorthBay Healthcare Group – Hospital Division v. Blue Shield of California Life & health Insurance, et al., No. 17-cv-02929, N.D. Calif., 2018 U.S. Dist. LEXIS 184180).

  • October 30, 2018

    Couple Tells 8th Circuit Insurer’s Air Transport Payment Unsupported By ERISA

    ST. LOUIS — A health insurer’s unsupported calculation of the allowable charge for air transport is a “radical view” of its powers under the Employee Retirement Income Security Act, would leave insureds with “virtually no coverage” and cannot withstand scrutiny, a couple tells the Eighth Circuit U.S. Court of Appeals in an Oct. 26 opening brief (Ivan Mitchell, et al. v. Blue Cross Blue Shield of North Dakota, et al., No. 18-2784, 8th Cir.).

  • October 29, 2018

    Health Care Provider Objects To Ruling Permitting Insurer’s Counterclaims

    SAN ANTONIO — An insurer’s counterclaim seeking offsets and alleging fraud are barred by a health care provider’s bankruptcy and the insurer’s failure to plead them with the required specificity, a hospital group told a federal court in Texas on Oct. 25 (Neil Gilmour III, et al. v. Aetna Health Inc., et al., No. 17-510, W.D. Texas).

  • October 24, 2018

    ACA Reinsurance Program Payments Not A Tax, 4th Circuit Rules

    RICHMOND, Va. — A health care plan’s payments under the Patient Protection and Affordable Care Act (ACA) reinsurance program do not constitute a tax, a panel of the Fourth Circuit U.S. Court of Appeals said Oct. 23 (The Electrical Welfare Trust Fund, et al. v. United States, et al., No. 17-1937, 4th Cir., 2018 U.S. App. LEXIS 29856).

  • October 24, 2018

    Court Seeks Evidence In Insurance Case Involving Assignment, Sovereignty Issues

    HOUSTON — A more thorough record must be developed before a court rules on how an anti-assignment clause and sovereign immunity impact an Employee Retirement Income Security Act case brought by a home dialysis company, a federal judge in Texas held Oct. 22 (Houston Home Dialysis v. Blue Cross and Blue Shield of Texas, et al., No. 17-2095, S.D. Texas).

  • October 23, 2018

    CMS Reports 75,000 Healthcare.gov Users’ Files Accessed In Data Breach

    BALTIMORE — The U.S. Centers for Medicare & Medicaid Services (CMS) announced Oct. 19 that it discovered “anomalous activity” in one of the portals of HealthCare.gov, which is the website through which Americans can obtain health insurance, per the Patient Protection and Affordable Care Act (ACA), 111 P.L. 148,124 Stat. 119. 

  • October 22, 2018

    Wisconsin Jury Awards $780,500 In Gender Dysphoria Insurance Discrimination Case

    MADISON, Wis. — A federal jury in Wisconsin on Oct. 11 awarded $780,500 to two transgendered individuals’ in their case alleging that their health plan’s exclusion on gender dysphoria treatment and services discriminated against them (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • October 22, 2018

    Judge Sends California Wilderness Therapy Coverage Class Action To Utah

    SAN FRANCISCO — A class action challenging a health insurer’s determination that mental health wilderness therapy was not medically necessary was sent to Utah Oct. 10 after a California federal judge noted that a similar action against the same defendant is already moving along in that forum (K.H.B., et al. v. UnitedHealthCare Insurance Co., No. 18-4175, N.D. Calif.).

  • October 17, 2018

    Magistrate Judge Won’t Sever Government-Sponsored Plan From Health Care Action

    CENTRAL ISLIP, N.Y. — While the employers, plans and claims differ, a chiropractor’s action seeking compensation for medical care he provided stems from a common health insurance administrator’s reliance on its internal guidelines, a federal magistrate judge in New York held Oct. 12 in denying a motion to sever one of the defendants and recommending that the court deny a motion to dismiss that defendant (Raymond A. Semente, D.C., P.C. v. Empire Healthcare, et al., No. 14-5823, E.D. N.Y., 2018 U.S. Dist. LEXIS 177086).

  • October 16, 2018

    Out-Of-Network Surgery Provider’s Reimbursement Suit Preempted, Judge Says

    TRENTON, N.J. — While brought under state law claims, a surgery provider’s action seeks reimbursement from an ERISA plan, and the fact that a court may have to only quickly reference that plan does not prevent preemption, a federal judge in New Jersey held Sept. 26 (The Plastic Surgery Center, P.A. v. Aetna Life Insurance Co., No. 17-13467, D. N.J., 2018 U.S. Dist. LEXIS 166514).

  • October 16, 2018

    Judge: De Facto Administrator Doctrine Doesn’t Apply To Health Benefits Manager

    MOBILE, Ala. — Precedent clearly limits the de facto administrator doctrine to employers and does not apply in a case naming an ERISA plan’s behavioral health benefits manager, a federal judge in Alabama held Sept. 26 (E.G., et al. v Companion Benefit Alternatives Inc., No. 18-265, S.D. Ala., 2018 U.S. Dist. LEXIS 165204).

  • October 15, 2018

    Judge Reopens Case Challenging Denial Of Coverage For Brand-Name Seizure Medicine

    TRENTON, N.J. — A federal judge on Oct. 10 reopened a case after the plaintiff filed an amended complaint he hopes cures deficiencies in his original complaint alleging that his health insurer improperly denied coverage for his brand-name seizure medication (Scott E. Tellep v. Oxford Health Plans, et al., No. 18-392, D. N.J.).

  • October 11, 2018

    Judge Widens Damages, Narrows Testimony In ACA Transgender Exclusion Case

    MADISON, Wis. — Two transgender individuals may seek damages for psychological pain and suffering they experienced from the alleged blanket discrimination in the form of a health plan’s exclusion for gender confirmation surgery, while the defendants’ past positions limit them to evidence that third-party insurers may have not have found the procedure medically necessary, a Wisconsin federal judge overseeing a Patient Protection and Affordable Care Act (ACA) discrimination case held Oct. 8 (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • October 10, 2018

    Insurers, Law Firm Settle ERISA Case Involving Asbestos Trust Fund Recoveries

    DALLAS — Health insurers and an asbestos litigation firm on Oct. 5 settled a Texas federal court case alleging that the firm withheld bankruptcy trust recoveries to which the Employee Retirement Income Security Act and Medicare insurance plans were contractually entitled for costs associated with treating the firm’s plaintiffs (Humana Inc., et al. v. Shrader & Associates LLP, No. 16-354, S.D. Texas).