502(A)(1)(B) Claim for Benefits

: : Plaintiff May Proceed On ERISA Claims Challenging Repricing of Provider Claims

Through this matter, Plaintiffs are attempting to stop Defendants allegedly improper practice of underbilling for chiropractic services that Plaintiffs provided to their patients. Presently before the Court are motions to dismiss the First Amended Complaint filed by the . . . Defendants. Plaintiffs allege that the Cigna and Aetna Defendants hired the Vendor Defendants to …

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: : Provider’s Claims Against CIGNA Dismissed For Failure to Allege Existence of Assignment of Benefits By Plan Participants

By the statute’s terms, only a “participant or beneficiary” may bring a claim. Pascack Valley Hosp. v. Local 464A UFCW Welfare Reimbursement Plan, 388 F.3d 393, 400 (3d Cir. 2004). Nonetheless, a healthcare provider may bring claims if it has a valid assignment of benefits from a plan participant. CardioNet, Inc. v. Cigna Health Corp., …

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: : Court Remands Insurer’s Recoupment Claims Against Provider to State Court Applying Davila Test

Here, plaintiff seeks damages in the amount of $226,562.62, which it contends make up the unpaid balance of overpayments to Dr. Gupta. BCBSLA’s complaint does not seek a constructive trust or an equitable lien on particular funds. Rather, it seeks to recover from Dr. Gupta’s assets generally. Thus, the Court finds that plaintiff’s claims are …

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: : Disability Insurer Policy Language Does Not Support ERISA Claim for Reimbursement of Overpayments

Provident offers a second theory of liability: equitable lien by agreement. Annual supplemental claims forms, signed and submitted by Messing between 2010 and 2017, contain the following language: “should my claim be overpaid for any reason, it is my obligation to repay any such overpayment.” (See, e.g., ECF No. 38-2, PageID.677 (2010 supplemental claim form).) …

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: : Ninth Circuit Panel Holds Against Insurer On Indemnification Claim

First Reliance cannot maintain a claim for contribution or indemnification against Armani. In Kim v. Fujikawa, the court concluded that 29 U.S.C. § 1109, as referenced in 29 U.S.C. § 1132(a)(2), “cannot be read as providing for an equitable remedy of contribution in favor of a breaching fiduciary.” 871 F.2d 1427, 1432 (9th Cir. 1989) …

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: : Discovery Permitted on Breach of Fiduciary Duty Claim Despite Overlap with Claim for Benefits

It is true that the claims overlap. But where they do, they operate as alternate theories of liability. Pleading multiple causes of action and alternative theories of liability is a standard practice of civil litigation. See F.R.C.P. Rule 8(a)(3). And it is permissible under ERISA. To further clarify, the Ninth Circuit has held that a …

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:: ERISA Plan Cannot Rely on Equitable Remedies To Supplement Subrogation Provision

“As an initial matter, the Court notes that this case is somewhat unusual. As stated above, plans often contain reimbursement provisions which expressly entitle them to seek reimbursement from beneficiaries who receive both plan benefits and third-party compensation. Consequently, litigation regarding reimbursement provisions generally centers around questions of application (i.e., whether recovery should be limited …

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:: “Heightened Arbitrary And Capricious Review” Questioned After Glenn

The district court used the framework that we established in Williams v. BellSouth Telecommunications, Inc., 373 F.3d 1132, 1137-38 (11th Cir. 2004), which provides a six-step process “for use in judicially reviewing virtually all ERISA-plan benefit denials”:(1) Apply the de novo standard to determine whether the claim administrator’s benefits-denial decision is “wrong” (i.e., the court …

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