In an unpublished opinion, the Fifth Circuit affirmed the dismissal of a class action suit that alleged the claim administrator, wrongfully denied payment of medical claims “immediately,” instead of waiting for the participant to fail to provide requested information. In this case, the plaintiff’s son was in an auto accident, and the administrator requested information regarding no-fault benefits before processing the medical claim. The self-funded plan at issue contained detailed provisions regarding Coordination of Benefits, primacy of coverage and information and records the insured is …
Continue ReadingAuthor: Sarah J. Delaney
Accidental Death Benefits are Payable Drowning, Even if Seizure Involved, was Cause of Death
In Chanthavong v. Union Security Ins. Co., (11/04/2014), the deceased, Corey Carter, was found in April of 2012, having accidentally drowned in his bathtub. Carter held a group life insurance policy established by his employer through defendant insurer that was subject to the provisions off the Employment Retirement Income Security Act. Carter named his son D.D.C., minor-plaintiff, the beneficiary on the policy. The defendant paid the general life insurance policy in full, but denied the claim under the accidental death policy, claiming the death was …
Continue ReadingSCOTUS Grants Cert on ACA Tax Subsidy Case
On Friday, November 7, 2014, the U.S. Supreme Court agreed to hear King v. Burwell, one of the cases about who is eligible for the tax subsidies in the Affordable Care Act (ACA). These subsidies are a critical part of the legislation as they are designed to help make health insurance affordable. As we discussed in a prior post, at least two U.S. Circuit Courts of Appeal have issued different interpretations on this language.
In King v. Burwell, the 4th Circuit …
Continue ReadingCigna Has Continued its Battle for Coverage of ERISA Class Action
Cigna has continued its fight for coverage again urging the Pennsylvania Superior Court to overturn a decision that let its excess insurers off the hook over an ERISA class action brought by the company’s employees. The dispute centers on changes to the benefit plan, which U.S. District Judge Janet Arterton’s 2012 decision found had been fraudulently altered. Cigna argues that this finding does not qualify as a fact finding, and that the fraud exemption was inaccurately applied.
Cigna’s argument has been that the finding relied …
Continue ReadingD.C. Court Agrees to Hear Halbig En Banc
On September 4, 2014, the U.S. Court of Appeals for the D.C. Circuit granted the U.S. Government’s petition to re-hear Halbig v. Burwell en banc which means that all active judges on the court will now hear the case.
For a more detailed explanation of the general arguments in Halbig, click here. However, in short, the question is whether the subsidies provided for by the Affordable Care Act for those who purchase health insurance through the exchanges apply to purchases from any exchange or …
Continue ReadingHealth Care Providers Ordered to Pay Insurer $8.4M for Billing Fraud
Three health care providers were forced to pay a judgment for defrauding an insurance company of millions of dollars. A Texas Federal Judge found that the defendant health care providers were wrongfully posing as emergency rooms in order to bill the insurance company at higher rates, in violation of Texas law.
The judge stated that a hospital sold the right to use its license-derived billing codes to various clinics in exchange for 15 percent of each of the clinics’ bills. The clinics then used these …
Continue ReadingObama Administration Files Proposed Rules on ACA Preventative Services Coverage–Seeks Input on Logistics
The Obama Administration has filed an Interim Final Rule seeking input on the logistics of obtaining an accommodation and in defining eligible organizations with respect to coverage for preventative services under the ACA.
The new interim final regulations establish another option for an eligible organization to avail itself of the accommodation. Under the IFR, an eligible organization may notify the Department of HHS in writing of its religious objection to contraception coverage. HHS will then notify the insurer for an insured health plan, or the …
Continue ReadingCourts Split on ACA Health Insurance Subsidies: Highlights Differences in Statutory Interpretation
On July 22, 2014, two U.S. Courts of Appeals highlighted both the science and the art of statutory construction and interpretation — and came to very different conclusions. These courts were asked to consider an IRS rule (26 C.F.R. § 1.36B-2(a)(1)) associated with a section of the Affordable Care Act that provides tax credits (subsidies) for those who purchase health insurance under the exchanges. The central issue was whether the relevant provision of the ACA (26 U.S.C. 36B(c)(2)(A)(i)) (the provision), which provides that subsidies would …
Continue ReadingThe Latest Insurance Law Decisions – Goldberg Segalla’s CaseWatch: Insurance is Now Available
Please click here for the latest edition of CaseWatch Insurance.
CaseWatch: Insurance provides timely summaries of and access to insurance law decisions and legislation. For ease of reference, we have organized cases by topic.
If you would like to receive future editions of CaseWatch: Insurance directly by email, please contact Sarah Delaney at [email protected].…
Continue ReadingHobby Lobby Precedent Already Undermined, Says Justice Sotomayor
Thursday, July 3, the United States Supreme Court granted an application for injunction pending appeal by Wheaton College, overriding its requirements for exemption from the contraceptive mandate under the Affordable Care Act, while calling into question the extent of the court’s holding in Burwell v. Hobby Lobby, Inc. In her dissent, Justice Sotomayor writes that this order “evinces disregard for even the newest of this Court’s precedents and undermines confidence in this institution.” Wheaton v. Burwell, 573 U.S. ____ (2014).
Wheaton College …
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