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 …
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 …
“ . . . [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 …
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 …
[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 …
Although Lumbermens has shown that the Summary Plan Description (“SPDâ€) unambiguously confers upon the Plan administrator discretionary authority to determine eligibility for benefits and to construe the terms of the plan, see Ingram v. Martin …