As Tennyson said, “the old order changeth, yielding place to new”, and so it is in claims appeals after the PPACA. This is one of several segments on the claims appeals and review process for health plans after the new legislation. In this segment, let’s look at the appeal process. Before the PPACA, ERISA only …
:: Claims Appeals – The New Order Of Affairs For ERISA Plans (Part I) Read More »
ERISA provides federal courts with jurisdiction to review benefits determinations made by fiduciaries or plan administrators. 29 U.S.C. § 1132(a)(1)(B); see also Lopez ex rel. Gutierrez v. Premium Auto Acceptance Corp., 389 F.3d 504, 509 (5th Cir. 2004). A district court’s function when reviewing ERISA claims is like an appellate court’s. “[The court] does not …
:: District Court Permits Supplementation Of Record But With Instruction On Law Read More »
“ . . . [I]n order for Principal to reasonably deny S.W.’s hospital charges, substantial evidence had to support its determination that the primary focus of her hospitalization was mental health treatment, i.e., treatment designed to alter her behavior. While there is certainly evidence that mental health treatment was one focus of S.W.’s hospitalization, we …
Eighth Circuit Holds Mental Health Treatment Limitation Inapplicable Read More »
People make mistakes. Even administrators of ERISA plans Conkright v. Frommert, 130 S. Ct. 1640 (U.S. 2010) The pithy statement quoted above, coupled with the comment that a “single honest mistake” does not alter the standard of review, seems destined to become the talismanic essence of what Conkright means to ERISA law. Starting from the …
Conkright In The Courts — Making Sense Of The Firestone Trilogy Read More »
[P]lan administrators must create written plan documents and offer members an opportunity to examine those documents to “determine exactly what [their] rights and obligations are under the plan.” Id. (quoting H.R. Rep. No. 93-1280, at 297 (1974), reprinted in U.S.C.C.A.N. 4639, 5077, 5078). Given the members’ right to examine the documents, the plan administrator must …
Stricter Review of Benefits Denial Where Plan Terms Inadequately Disclosed Read More »
