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Mealey's Health Care / ACA

  • August 1, 2018

    Judge Dismisses ACA, Civil Rights Claims From AIDS Drug Discrimination Case

    NASHVILLE, Tenn. — An insurer’s policy requiring that certain prescriptions be filled at specialty pharmacies appears to cover drugs disabled individuals would use and those used by others, dooming a man’s class action lawsuit alleging discrimination under the Patient Protection and Affordable Care Act (ACA), a federal judge in Tennessee said July 30 (John Doe, et al. v. Bluecross Blueshield of Tennessee Inc., No. 17-2793, W.D. Tenn.; 2018 U.S. Dist. LEXIS 126845).

  • July 31, 2018

    Insolvent Insurer Seeks Rehearing In Case Over ACA Risk-Corridor Payments

    WASHINGTON, D.C. — An insolvent health insurer on July 30 asks that the Federal Circuit U.S. Court of Appeals grant rehearing en banc, vacate its decision and enter judgment against the United States for billions in Patient Protection and Affordable Care Act (ACA) risk-corridor funds (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 17-1224, Fed. Cir.).

  • July 27, 2018

    States Say Association Health Plan Rule Violates ERISA, ACA

    WASHINGTON, D.C. — A U.S. Department of Labor final rule twists the Employee Retirement Income Security Act, permitting associations to offer non-Patient Protection and Affordable Care Act (ACA)-compliant health plans and “increases the risk of fraud and harm to consumers, requires states to redirect significant enforcement resources to curb those risks, and jeopardizes state efforts to protect their resident through stronger regulation.  The rule is unlawful and should be vacated,” numerous states complain in a July 26 lawsuit filed in District of Columbia federal court (New York, et al. v. U.S. Department of Labor, et al., No. 18-1747, D. D.C.).

  • July 26, 2018

    Father Claims Insurer Improperly Denied Autistic Son Behavioral Services

    NEW YORK — A health insurer denied necessary behavioral health treatments for a severely autistic individual despite plan language imposing no limitations or exclusions on such services, the patient’s father claims in a July 25 complaint in New York federal court (Harry DeMeo, M.D.,  et al. v. Oxford Health Plans [NY] Inc., et al., No. 18-5208, E.D. N.Y.).

  • July 24, 2018

    Judge Permits Potentially Duplicative ERISA Claims At Pleading Stage

    TRENTON, N.J. — It’s possible that a medical provider could prevail under contractual ERISA claims or on a count seeking other relief, and at this stage pleading both is permissible, a federal judge in New Jersey held July 20 (University Spine Center v. Aetna Inc., et al., No. 17-8747, D. N.J.).

  • July 23, 2018

    Judge Rules Deaf Man’s ACA Discrimination Claim May Proceed

    NEW ORLEANS — The Patient Protection and Affordable Care Act (ACA) incorporates the definition of discrimination and prerequisites for filing suit from other statutes that do not require exhaustion of administrative remedies in cases involving federal grantees, a federal judge in Louisiana said July 17 (Joseph Lockwood v. Our Lady of the Lake Hospital Inc., No. 17-509, M.D. La.).

  • 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).