Mealey's Health Care / ACA

  • July 29, 2021

    California Supreme Court Will Review Medical Group’s UCL Claim Against Insurer

    SAN FRANCISCO — The California Supreme Court on July 28 granted a medical association’s petition for review of an appellate panel’s ruling that the association lacked standing to bring an unfair competition law (UCL) claim against an insurer for its practice of restricting physicians from making referrals to out-of-network doctors, but denied an amici request for depublication of the underlying opinion.

  • July 29, 2021

    Judge Affirms Denial Of Benefits In Mental Health ERISA Case

    NEW ORLEANS — The burden of showing applicability of a health plan exception where in-network care was unavailable within 75 miles of a residence falls on the insured, and the record is devoid of evidence that an insurer improperly denied a man’s claim for mental health and substance abuse treatment, a federal judge in Louisiana said July 26 in affirming a denial of Employee Retirement Income Security Act benefits.

  • July 28, 2021

    Insurer: Interlocutory Appeal Provides Fast Fix To ACA Discrimination Claim

    INDIANAPOLIS — A nursing home operator’s health plan asks the Seventh Circuit U.S. Court of Appeals in a July 27 petition for interlocutory review to consider whether the company’s receipt of federal funds gives one of its insureds standing to challenge denial of coverage for applied behavioral analysis treatments under the Patient Protection and Affordable Care Act (ACA) provision prohibiting discrimination.

  • July 26, 2021

    5th Circuit Vacates, Remands For Dismissal Of ACA Individual Mandate Case

    NEW ORLEANS — Responding to the U.S. Supreme Court’s June decision finding two individuals and a collection of states lacked standing to challenge the Patient Protection and Affordable Care Act (ACA) individual mandate, the Fifth Circuit U.S. Court of Appeals vacated a federal judge’s ruling and remanded the case for dismissal on July 22.

  • July 23, 2021

    Supreme Court Asks Provider To Weigh In On Medicare-Dialysis Case

    WASHINGTON, D.C. — The U.S. Supreme Court on July 21 requested that a medical provider respond to a joint petition after the company previously indicated that it would not do so.

  • July 23, 2021

    Georgia Insureds: Medical Network Suit Doesn’t Implicate Filed-Rate Doctrine

    ATLANTA — A lawsuit alleging that an insurer overstated the extent of its network never invokes claims that the insurer overcharged for premiums or misled the state into approving the premiums but instead involves breach of contract and deceptive business practices claims that do not implicate the filed-rate doctrine, insureds told a Georgia appeals court on June 22.

  • July 23, 2021

    Judge Sorts Through Uncertainty Of Parity Act Standard, Denies Dismissal

    GREEN BAY, Wis. — Given the uncertainty around how to plead Parity Act claims, a judge on July 22 said in denying a motion to dismiss that he would rely on recent precedent requiring allegations that an insurer imposes more restrictive standards on mental health and substance abuse claims.

  • July 22, 2021

    6th Circuit Affirms ACA Age Discrimination, Expert Opinion Rulings

    CINCINNATI — The Patient Protection and Affordable Care Act (ACA) incorporates standards from the discrimination statutes from which it borrows, including administrative exhaustion requirements, a court properly admitted experts on the question of the medical appropriateness of an elderly woman’s transfer, and without experts of his own, a son lacks the necessary evidence for his remaining claims, a Sixth Circuit U.S. Court of Appeals panel said July 20 in affirming dismissal and summary judgment rulings.

  • July 22, 2021

    Man To 6th Circuit: 4-Year Statute Of Limitations On ACA Discrimination Claim

    CINCINNATI — The Patient Protection and Affordable Care Act (ACA) borrows burdens and standards from discrimination laws, not their statute of limitations, and nothing in the law or precedent suggests otherwise, a deaf man tells the Sixth Circuit U.S. Court of Appeals July 20 in urging the court to apply a four-year period to his ACA claim.

  • July 22, 2021

    Class Counsel Seeks Approval Of Attorney Fees In ACA Risk-Corridor Funds Suit

    WASHINGTON, D.C. — Class counsel on July 20 moved for the U.S. Court of Federal Claims to approve their attorney fee request of 5 percent of a $45,417,643.02 judgment for a subclass that consists of one insolvent insurer in insolvent insurers’ lawsuit seeking a declaratory judgment that the U.S. government owes them millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program.

  • July 21, 2021

    Judge Adopts Report Finding ERISA Assignment Gives Bankruptcy Trustee Standing

    DALLAS — Insureds’ assignment to medical providers included both rights to benefits under the Employee Retirement Income Security Act and legal action and transferred to the trustee upon the providers’ bankruptcy, a federal judge in Texas said July 19 in adopting a magistrate judge’s report recommending denial of a motion to dismiss.

  • July 16, 2021

    Judge: No Evidence Residential Treatment Was Medically Necessary

    SEATTLE — Insureds have not shown that more than a year of residential treatments were medically necessary under their health plan, a federal judge in Washington said July 15 in granting the insurer judgment after remand from the Ninth Circuit U.S. Court of Appeals.

  • July 16, 2021

    Judge Certifies Federal Funds Recipient ACA Standing Question For Appeal

    INDIANAPOLIS — Binding precedent requires finding plaintiffs may pursue a discrimination claim against a recipient of federal funds under the Patient Protection and Affordable Care Act (ACA) and Rehabilitation Act, but the 41-year-old precedent could use a fresh look by the appellate court, a federal judge in Indiana said July 14 in denying reconsideration but granting interlocutory review.

  • July 13, 2021

    Conclusory Statements Can’t Establish Valid Benefit Assignments, Judge Says

    TRENTON, N.J. — Conclusory statements do not establish the existence of assignment of rights where plaintiffs have not produced a single valid document for any of the 11 individuals, a federal judge in New Jersey said July 9 in dismissing Employee Retirement Income Security Act claims in a health insurance coverage case.

  • July 12, 2021

    Insurer Says California Supreme Court Need Not Review Medical Group’s UCL Standing

    LOS ANGELES — An insurer argues in a June 28 response brief to the California Supreme Court that no conflict of law or important issue meriting review exists in a panel’s ruling that a medical association lacked standing to bring a California unfair competition law (UCL) claim against the insurer for restricting physicians from making referrals to out-of-network doctors because the association did not demonstrate that it was injured.

  • July 09, 2021

    Acute Care Allegations Keep Parity Act Claims Alive, Judge Holds

    SALT LAKE CITY — A woman’s Parity Act claims alleging improper denial of coverage for residential treatments sufficiently allege that the insurer imposes acute level care requirements in such settings, a federal judge in Utah said June 21 in denying a motion to dismiss.

  • July 09, 2021

    Causation, Top Court Ruling Feature In Post-Briefing Letters By Insurer, Class

    SAN FRANCISCO — Parties to a dispute over coverage and payment for care at residential treatment centers recently filed post-briefing letters with the Ninth Circuit U.S. Court of Appeals on the impact of the recent U.S. Supreme Court ruling in TransUnion LLC v. Ramirez, No. 20-297 (June 25, 2021) and on whether the insurer misstated the causation issue in its briefs or if the class was simply attempting to file a sur-reply “in the guise of purported error correction.”

  • July 06, 2021

    ERISA Preempts Medical Provider’s Suit Against NFL, 5th Circuit Says

    NEW ORLEANS — Resolving a medical provider’s claim that the National Football League interfered with economic advantage by directing its insurer to classify health care claims as work related necessarily requires probing an Employee Retirement Income Security Act plan, and the statute completely preempts the state law claim, a Fifth Circuit U.S. Court of Appeals panel said July 1.

  • July 02, 2021

    Supreme Court Takes Up Emotional Distress Damages In ACA Discrimination Case

    WASHINGTON, D.C. — The Supreme Court on July 2 agreed to decide whether emotional distress damages are available in a deaf and blind woman’s Patient Protection and Affordable Care Act (ACA) case alleging that a medical provider breached federal law by discriminating against her.

  • July 02, 2021

    High Court Accepts ACA Disparate Impact Discrimination Case

    SAN FRANCISCO — The U.S. Supreme Court on July 2 agreed to review whether the interplay between the Patient Protection and Affordable Care Act (ACA) and the Rehabilitation Act permits disparate impact discrimination claims in a class action alleging that a pharmacy’s restrictions on HIV/AIDS drug delivery discriminated against sufferers.