SAN FRANCISCO — Mental health treatments planned well in advance of hospitalization were not emergency services covered by an Employee Retirement Income Security Act health plan, and because the insureds never sought preauthorization from their insurer, the out-of-network coverage provision does not apply, a Ninth Circuit U.S. Court of Appeals panel held April 6 (Carol Meyers v. Kaiser Foundation Health Plan Inc., No. 19-15051, 9th Cir., 2020 U.S. App. LEXIS 10704).
DENVER — An insurer did not act in an arbitrary or capricious way when it credited certain medical opinions over those of treating physicians or when it denied coverage for residential mental health treatment, a 10th Circuit U.S. Court of Appeals panel held April 3 (Tracy O., et al. v. Anthem Blue Cross Life and Health Insurance, et al., No. 17-4135, 10th Cir.).
GREENSBORO, N.C. — The Patient Protection and Affordable Care Act (ACA) and other federal statutes preventing discrimination apply to gender dysphoria exclusion claims against North Carolina universities and related entities, a federal judge said March 11 in denying motions to dismiss (Maxwell Kadel, et al. v. Dale Folwell, et al., No. 19-272, M.D. N.C., 2020 U.S. Dist. LEXIS 42586).
BOSTON — A family adequately alleges that an insurer’s denial of coverage for mental health care violates the Parity Act and the Employee Retirement Income Security Act, a federal judge in Massachusetts said March 30 (Steve C., et al. v. Blue Cross and Blue Shield of Massachusetts Inc., et al., No. 18-12278, D. Mass., 2020 U.S. Dist. LEXIS 54857).
SALT LAKE CITY — A family adequately alleges that a health insurance plan’s blanket exclusion on wilderness treatments sufficiently deviates from how it covers similar treatments in the medical or surgical setting to keep the claim alive, and there is no reason at this stage to believe that the Parity Act claim is duplicative of the claim seeking benefits, a federal judge in Utah said March 26 (Candace B., et al. v. Blue Cross and Blue Shield of Rhode Island, No. 19-39, D. Utah, 2020 U.S. Dist. LEXIS 52850).
NEW ORLEANS — An out-of-network surgery provider’s breach of contract and detrimental reliance claims are adequately pleaded and avoid Employee Retirement Income Security Act (ERISA) preemption, but the remainder of the case fails, a federal judge in Louisiana held March 30 while denying a blanket request for an “attorneys’ eyes only” provision (Crescent City Surgical Centre v. Cigna Health and Life Insurance Co., et al., No. 18-11385, E.D. La., 2020 U.S. Dist. LEXIS 54556).
NEW YORK — A medical billing expert is qualified to testify, and medical providers’ benefits recovery and injunctive relief claims largely survive in a case alleging that an insurer ignored plan language and instead issued automatic denials of coverage for office-based practices’ facility fees, a federal judge in New York said March 26 (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y., 2020 U.S. Dist. LEXIS 53262).
BOSTON — A woman’s Employee Retirement Income Security Act class action seeking disgorgement and an injunction barring an insurer from denying proton beam therapy claims simply repackages a denial of benefits claim and must be dismissed without prejudice, a federal judge in Massachusetts said March 25 (Kate Weissman v. United Healthcare Insurance Co., et al., No. 19-10580, D. Mass., 2020 U.S. Dist. LEXIS 51568).
HARTFORD, Conn. — The portion of a class of Medicare beneficiaries placed on observation status after being admitted the hospital as inpatients and now suing the federal government for depriving them of their property interest in Part A coverage have shown that the U.S. secretary of Health and Human Services (HHS) violated the due process clause of the Fifth Amendment to the U.S. Constitution, a federal judge in Connecticut ruled March 24, ordering that those members should be permitted to appeal the denial of their coverage (Christina Alexander, et al. v. Alex M. Azar II, No. 11-1703, D. Conn., 2020 U.S. Dist. LEXIS 50636).
BATON ROUGE, La. — According to the court’s docket, a federal judge on March 23 continued the May 11 trial date for a health care discrimination case involving a deaf women after the parties pointed out the state of emergency and that the health care professionals involved in the battle against the novel coronavirus at the heart of the state’s “stay-at-home” order will comprise nearly all the trial’s witnesses (Katrina Rivers LaBouliere, et al. v. Our Lady of the Lake Hospital Inc., No. 16-785, M.D. La.).
ROCHESTER, N.Y. — Outside reviews and treatment records support an insurer’s conclusion that a child’s mental health issues could have been treated at a lower level of care, a federal judge in New York held March 19, finding that the insurer properly denied coverage for wilderness treatments (Julie L., et al. v. Excellus Health Plan Inc., et al., No. 18-6753, W.D. N.Y., 2020 U.S. Dist. LEXIS 47734).
BROOKLYN, N.Y. — In granting financial hardship waivers, a health care provider did not fraudulently misrepresent claims it submitted to an insurer nor interfere with the insurer’s contract with insureds, a New York appellate court affirmed March 18 (Oxford Health Plans [NY] Inc., et al. v. Biomed Pharms Inc., No. 2017-02971, N.Y. Sup., App. Div., 2nd Dept., 2020 N.Y. App. Div. LEXIS 1946).
ST. LOUIS — An insurer properly reimbursed an air-ambulance transport company for services it provided to an insured, and there is insufficient evidence that its explanation was a post hoc litigation defense, an Eighth Circuit U.S. Court of Appeals panel said March 20 in affirming two judgments and reversing a third (Ivan Mitchell, et al. v. Blue Cross Blue Shield of North Dakota, et al., No. 18-2784, Ivan Mitchell, et al. v Blue Cross Blue Shield of North Dakota, et al., No. 18-2890, 8th Cir., 2020 U.S. App. LEXIS 8818).
CENTRAL ISLIP, N.Y. — A more full record allows for the conclusion that an anti-assignment provision prevents a chiropractor’s New York breach of contract claim, a federal judge in New York said March 17 in denying him summary judgment and entering a take-nothing judgment (Raymond A. Semente, D.C., P.C. v. Empire Healthcare, et al., No. 14-5823, E.D. N.Y., 2020 U.S. Dist. LEXIS 45276).
TRENTON, N.J. — A sleep center’s reconsideration motion largely reargues points already rejected, but even those arguments do not suggest that the Employee Retirement Income Security Act does not preempt the claims, a federal judge in New Jersey said Feb. 27 (Sleep Tight Diagnostic Center LLC v. Aetna Inc., et al., No. 18-3556, D. N.J.).
NEW YORK — An assignment of rights gives a medical provider standing under the Employee Retirement Income Security Act, and the statute preempts his state law action, a New York justice held March 12 (Bassel v. Aetna Health & Life Ins. Co., 8280/19, N.Y. Sup., Queens Co.).
WASHINGTON, D.C. — Petitioners and a host of amicus curiae parties told the Supreme Court in a plethora of briefs filed between March 2 and March 9 that the Patient Protection and Affordable Care Act (ACA) and Religious Freedom Restoration Act (RFRA) permit religious and moral exemptions to the contraceptive mandate (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, et al., Donald J. Trump, et al. v. Pennsylvania, Nos. 19-431, 19-454, U.S. Sup.).
BOSTON — Clear error review in an Employee Retirement Income Security Act mental health benefits case requires an evidentiary hearing to ensure that the court does not erroneously read the record as a judge did in determining that residential treatments were not medically necessary in the absence of acute symptoms, a woman said in March 9 briefing to the First Circuit U.S. Court of Appeals (Jane Doe v. Harvard Pilgrim Health Care Inc., et al., No. 19-1879, 1st Cir.).
AUSTIN, Texas — An insurance group’s challenge to Texas rules governing insurance payments for out-of-network care are not precluded by governmental immunity, a state appeals court held March 9 (Texas Department of Insurance v. Texas Association of Health Plans, No. 03-19-00185-CV, Texas App., 3rd Dist., 2020 Tex. App. LEXIS 1872).
NEWARK, N.J. — An insurer outsourced the handling of out-of-network insurance claims, giving it no fiduciary role in a provider’s attempts at recovering $595,833.53, a federal judge in New Jersey said March 6 (IJKP Opco LLC, et al. v. General Trading Co, et al., No. 17-6131, D. N.J., 2020 U.S. Dist. LEXIS 39585).