Category: Life, Health, Disability & ERISA

Blue Shield of California v. Harlick
Petition for Writ of Cert from U.S. Ct. Apps. 9th Cir., (filed Oct. 10, 2012)

The Petition for Cert comes after the Ninth Circuits ruling that barred Blue Shield from considering on remand whether the plaintiff’s services were medically necessary. The court held that the ERISA plan had waived its right to conduct an investigation and to potentially make the medically necessary determination because it did not identify those specific grounds in its initial denial. Under this ruling, the …

Stephan v. Unum Life Ins. Co. of Am.
U.S. Ct. Apps. 9th Cir., Sept. 12, 2012
The ERISA challenge was brought based on the insurer’s calculation of pre-disability benefits. The Court of Appeals agreed with the district court that the applicable standard of review was abuse of discretion and that because the insurer was responsible both for evaluating benefits claims and paying them, it operated under a conflict of interest, which had to be weighed as a factor in determining whether there was an abuse …

Lynam v. Health Plan of Nevada (Nev. March 21, 2012)

The plaintiff, Donald Lynam, received managed health care services from a health plan.  As part of his “managed care,” he was referred by the health plan to a medical services provider for treatment.  During the course of his treatment, allegedly through the unsafe practices of the provider, he contracted hepatitis C.  He sued the health plan asserting that the plan “knew or should have known” about the unsafe conditions and failed to have a quality …

The Supreme Court today began a record three-day session to hear oral argument on the constitutionality of President Obama's Patient Protection and Affordable Care Act. In today's 90-minute hearing, the high court considered arguments on the issue of whether it has jurisdiction in the case, or must wait until the law goes into effect and is enforced with penalties after 2014. The justices appeared to favor the view that the Anti-Injunction Act — which bars legal action to impose prior restraint on Congress' power to …

SCHULTZ v. AVAILL, INC. LONG TERM (7^th Cir. March 2, 2012)

Proposed class-action plaintiffs sought a ruling that Social Security Benefits provided to children of disabled parents did not constitute “loss time disability payments,” subject to an offset under long-term disability insurance. 

According to the opinion, the plaintiffs argued that the dependent payments were “additional” and did not constitute replacement of income: “Essentially, they argue, the purpose of Social Security payments to a dependent child of a disabled parent is not to replace the …

Federal Ins. Co. v. IBM N.Y. Ct. Apps., Feb. 21, 2012

The Court of Appeals unanimously affirmed the lower court’s decision declaring that the excess insurer was not required to indemnify the insured where the alleged ERISA claims were not covered under the underlying policy. The issue was whether the allegations against the insured included a breach of fiduciary duties imposed under ERISA.

The underlying policy provides coverage only for the insured’s violations when acting in an ERISA fiduciary capacity. The excess policy was a …

Gooch v. Life Investors Ins. Co. of Am. Et al., (United States Court of Appeals for the Sixth Circuit February 10, 2012)

The Sixth Circuit vacated an order of class certification for cancer patients because there was an overlap between class members of this class and a class that had settled on the same issue in another case. Despite this, the Court upheld a preliminary injunction forcing the defendant to pay for the plaintiff’s lymphoma treatment bills in full.

The plaintiff brought a claim against …

United Food & Comm. Workers Unions v. Walgreen Co. U.S. Dist. Ct., N.D. Ill, Filed Jan. 11, 2012

Insurance companies, self-insured employers, and union health and welfare plans filed the class action in Illinois Federal Court alleging several RICO violations against Walgreen Co. and Par Pharmaceutical Co. for engaging in a scheme to overcharge for generic versions of Zantac and Prozac.

Walgreen and Par entered into a “health resource partnership” under which Par manufactured and marketed generic versions of the drugs Zantac and Prozac in …

Koberg v. John Alden Life Ins. Co. U.S. Dist. Ct. (Mont.) Dec. 8, 2011

The District Court of Montana dismissed a putative class action against insurer John Alden last Thursday citing the Policy’s 3-year statute of limitations. The plaintiff brought suit against the insurer alleging it had used a defective database that produced inaccurate calculations for reimbursement of health care charges. Plaintiff was insured under an ERISA-governed employee welfare benefit plan that included medical coverage.

In 2005, the insured incurred more than $20,000 in health …

Plasterers’ Local Union No. 96 Pension Plan v. Pepper (U.S. Ct. of Apps., 4th Cir., Dec. 1, 2011)

Former trustees of Local Union 96 appealed a district court ruling that they had breached their fiduciary duties regarding investment of plan assets as required under ERISA section 1104(a)(1)(B) and (C). The former trustees presented evidence that in the 1970’s and 80’s the predecessor plan fund had lost substantial amounts of funds and therefore, in 1987 the board implemented the plan with the primary objective to …