Mealey's Health Care / ACA

  • October 27, 2021

    5th Circuit Asked To Reconsider Review Standard For ERISA Benefit Denials

    NEW ORLEANS — In an Oct. 6 petition for rehearing en banc regarding a panel decision that upheld a health plan benefit denial, an appellee asks the Fifth Circuit U.S. Court of Appeals to reevaluate its “substantial evidence” standard for reviewing such denials under the Employee Retirement Income Security Act, noting a concurring opinion that cited U.S. Supreme Court decisions in questioning the standard.

  • October 26, 2021

    Class: ACA Focuses On Effects, Permits Disparate Impact Discrimination Claims

    SAN FRANCISCO — The Patient Protection and Affordable Care Act and an underlying anti-discrimination statute focus on individuals and effects of conduct, not the actor or intent, respondents tell the U.S. Supreme Court in an Oct. 22 brief arguing that the laws permit disparate impact claims.

  • October 25, 2021

    Judge: State, Common-Law Health Care Payment Claims Escape ERISA Preemption

    HARTFORD, Conn. — State and common-law claims based on an insurer’s alleged promise to pay are based on a duty independent of those imposed by the Employee Retirement Income Security Act and are not subject to preemption, a federal judge in Connecticut said in partly denying a motion to dismiss Sept. 30.

  • October 20, 2021

    Insurer, Fiduciary Escape Orthopedic Provider’s ERISA Claims

    TRENTON, N.J. — A provider of orthopedic procedures improperly casts an insurer who merely performs ministerial tasks as a fiduciary and never adequately alleges that the actual fiduciary violated any obligations under the Employee Retirement Income Security Act, a federal judge in New Jersey said Oct. 18 in granting dismissal.

  • October 20, 2021

    Judge Finds Record Supports Insurer’s Residential Treatment Denials

    SALT LAKE CITY — A federal judge in Utah on Oct. 15 granted final judgment in favor of an insurer after concluding that the record supports the conclusion that a child did not medically require residential treatments past the point where the insurer ceased coverage and that while the health care plan’s language might violate the Parity Act, there is no evidence that it caused the conduct in this case.

  • October 19, 2021

    ACA Discrimination Claimant Not A Protected Interest, Insurer Tells 7th Circuit

    CHICAGO — The Affordable Care Act and the underlying statute it borrows from to bar discrimination protect patients, putting an individual suing his insurer over its decision to deny coverage for applied behavioral analysis (ABA) outside the scope of protected interests, the company tells the Seventh Circuit U.S. Court of Appeals in a Sept. 27 brief in urging judgment in its favor.

  • October 19, 2021

    Surgery Providers’ Claims Reference ERISA Plan, Federal Judge Says

    BATON ROUGE, La. — Letters from an insurer allegedly promising in-network payment rates do not formalize the amount of the payment and require analysis of an Employee Retirement Income Security Act plan, a federal judge in Louisiana said Sept. 28 in granting an insurer partial summary judgment.

  • October 19, 2021

    Judge Won’t Dismiss, But Transfers Wilderness Therapy Coverage Case

    SALT LAKE CITY — A federal judge in Utah declined to dismiss a wilderness therapy coverage action brought under the Employee Retirement Income Security Act for lack of personal jurisdiction, but granted transfer to Washington federal court on Sept. 29.

  • October 19, 2021

    Emergency Care Groups’ RICO, Contract Claims Against Insurer Proceed

    PHOENIX — A group of out-of-network emergency care providers adequately alleges that years of payments at a given rate created implied contract and Racketeer Influenced and Corrupt Organization claims “even if just barely so,” but state statutes target consumer transactions not at issue in the provider-insurer spat or lack a private right of action, an Arizona judge said Sept. 23 in partially granting a motion to dismiss.

  • October 19, 2021

    $1.7M Settlement Gets Final Approval In Parity Suit Over Therapy For Autism

    SEATTLE — A federal judge in Washington on Oct. 8 granted final approval to an agreement settling allegations that a health plan violated the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) by excluding coverage for two specific types of therapy for autism spectrum disorder (ASD); the agreement includes prospective coverage of the therapies and up to $1.7 million for retrospective claims for unreimbursed therapy costs.

  • October 18, 2021

    Court Grants Solicitor General Role In ACA Emotional Distress Discrimination Case

    WASHINGTON, D.C. — The U.S. Supreme Court on Oct. 18 granted the acting solicitor general permission to participate in oral argument, divided argument and an enlargement of time for argument after a medical provider and a supporting amicus curiae told the court in Sept. 29 and Oct. 5 briefs that nothing in precedent, congressional intent or common law supports permitting emotional distress damages in a deaf woman’s Patient Protection and Affordable Care Act (ACA) health care discrimination case.

  • October 15, 2021

    Appeals Court Won’t Reinstate Calif. Unfair Competition Law Hospital Pricing Suit

    SAN FRANCISCO — Even under the most generous standard a man never establishes that a hospital’s failure to disclose that it imposes an emergency room fee separate from its listed charges constitutes unfair conduct under the California unfair competition law (UCL) or the California Consumers Legal Remedies Act (CLRA), a California appeals court said in affirming dismissal of the case Oct. 13.

  • October 14, 2021

    Parties Seek Remand Of Appeal Over Single Case Agreements, Say They May Settle

    BOZEMAN, Mont. — Parties in an Oct. 6 motion ask a federal appeals court for conditional remand of an appeal over a judge’s conclusion that a mental health provider’s agreement with other Blue Cross entities could serve as the benchmark for an award of benefits in an Employee Retirement Income Security Act benefits case, saying a settlement likely resolved the case.

  • October 14, 2021

    Objecting Class Members Appeal Attorney Fees Awards In ACA Risk-Corridor Dispute

    WASHINGTON, D.C. — Objecting class members on Oct. 1 appealed the U.S. Court of Federal Claims’ judgments granting attorney fee awards for class counsel of insurers in a lawsuit seeking a declaratory judgment that the U.S. government owes the insurers millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program.

  • October 12, 2021

    Cap On Nonemergent Care By Emergency Providers Survives Tennessee Court

    NASHVILLE, Tenn. — A $50 cap placed on nonemergent care provided in an emergency setting to those covered under Tennessee’s Medicaid program is akin to internal government management and is not subject to rule making requirements under the Uniform Administrative Procedures Act, a Tennessee appeals court said Oct. 7 in reversing a summary judgment ruling.

  • October 11, 2021

    ERISA Insurer Appeals Ruling Finding Residential Treatment Coverage Denial Arbitrary

    SALT LAKE CITY — An insurer on Sept. 22 filed an amended notice appealing a Utah federal judge’s opinion finding that the insurer’s improper and inconsistent grounds for denying coverage for residential treatments were arbitrary and entitled the plaintiffs to partial summary judgment on their Employee Retirement Income Security Act claim.

  • October 06, 2021

    Provider, Insurer Grapple Over Supreme Court Review In Medicare-Dialysis Case

    SAN FRANCISCO — A provider tells the U.S. Supreme Court in a Sept. 21 brief that it should ignore manufactured urgency over an alleged spilt between two circuit courts involving Medicare and insurer discrimination against end-stage renal disease (ESRD) sufferers, but in an Oct. 4 reply, a health plan tells the court that the circuit split is obvious and that review is warranted.

  • October 06, 2021

    ACA Discrimination Case Lacks Emotional Distress Award, Provider, Amicus Say

    WASHINGTON, D.C. — A medical provider and a supporting amicus curiae tell the U.S. Supreme Court in Sept. 29 and Oct. 5 briefs that nothing in precedent, congressional intent or common law supports permitting emotional distress damages in a deaf woman’s Patient Protection and Affordable Care Act (ACA) health care discrimination case.

  • October 04, 2021

    Class May File Cert Petition Challenging ERISA Fiduciary Ruling Under Seal

    WASHINGTON, D.C. — The U.S. Supreme Court on Oct. 4 said a class can file under seal a petition for a writ of certiorari and associated supplemental appendix challenging a Second Circuit U.S. Court of Appeals panel ruling affirming that Anthem and Express Scripts Inc. (ESI) were not acting as fiduciaries under the Employee Retirement Income Security Act when they set prescription drug prices.

  • October 01, 2021

    Judge: State Law Claims Survive ERISA; ACA Lacks Private Right Of Action

    TRENTON, N.J. — The Employee Retirement Income Security Act does not preempt state law claims based on an insurer’s alleged promise to pay for acute care, but there is no evidence that the Patient Protection and Affordable Care Act (ACA) created a private right of action to enforce alleged violations of its essential benefits provision, a federal judge in New Jersey said Sept. 29.

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