Uncategorized

:: The Myth Of the “Partially Self-Insured” Group Health Plan

Dewitt and her husband, Anthony, were covered under Proctor’s health insurance plan. Throughout Dewitt’s tenure at Proctor, Anthony suffered from prostate cancer and received expensive medical care. His covered medical expenses were paid by Proctor, which was partially self-insured. It paid for members’ covered medical costs up to $250,000 per year. Anything above this “stop-loss” …

:: The Myth Of the “Partially Self-Insured” Group Health Plan Read More »

:: Workers’ Compensation Settlements Vulnerable To Recoupment

While the Court is not unsympathetic to Defendants, it recognizes that the Fund has a fiduciary responsibility to enforce its lien on the proceeds of Defendants’ workers’ compensation settlements in order maintain the solvency of the Fund for the benefit of all participants. This unpleasant episode, which results in Defendants getting less money for their …

:: Workers’ Compensation Settlements Vulnerable To Recoupment Read More »

:: Refund Requests Prove Shortest Route To Group Health Plan Reimbursement

Plaintiff relies on a provision titled, “Third-Party Liability (Subrogation)” but Premera is not asserting subrogation rights. Premera might have asserted subrogation rights if Allied had not paid the PIP benefit, but Allied did so. Nor did Premera assert subrogation rights when it sought reimbursement from the providers because those providers were not liable to plaintiff. …

:: Refund Requests Prove Shortest Route To Group Health Plan Reimbursement Read More »

:: Fourth Circuit Rejects Argument That Plan Implicitly Conferred Discretionary Authority

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), establishes the principle that courts review de novo an ERISA benefits determination unless the plan confers discretionary authority on its administrator. In this case we again confront the question of exactly what language is sufficient under Firestone to confer discretion on a plan administrator …

:: Fourth Circuit Rejects Argument That Plan Implicitly Conferred Discretionary Authority Read More »

:: Revisiting The Concept Of Standing As A Defense To ERISA Actions After LaRue

Finally, we should note that while the LaRue Court only decided statutory standing in its opinion, it did not ignore constitutional standing, nor could it have ruled on statutory standing had the requirements of constitutional standing not been satisfied. Wangberger v. Janus Capital Group (In re Mut. Funds Inv. Litig.), 2008 U.S. App. LEXIS 12690 …

:: Revisiting The Concept Of Standing As A Defense To ERISA Actions After LaRue Read More »

:: MetLife Decision Handed Down – Supreme Court Affirms The Sixth Circuit

SCOTUSBLOG has announced that the Supreme Court has released the opinion in MetLife v. Glenn(06-923).  The key issue before the Court in that case was whether the fact that a claim administrator of an ERISA plan also funds the plan benefits creates a “conflict of interest” that must be weighed in a judicial review of …

:: MetLife Decision Handed Down – Supreme Court Affirms The Sixth Circuit Read More »

:: Active At Work Issue Resolved Against Health Insurer In $650,000 Benefit Dispute

If a health insurer issues coverage to an employer group, stipulating that coverage is available to employees regularly working 30 hours per week, who may decide whether an employee meets the eligibility requirement – the employer or the health insurer? That was the issue in Carolina Care Plan v. Audie Brown Auto Sales, a case …

:: Active At Work Issue Resolved Against Health Insurer In $650,000 Benefit Dispute Read More »

:: Seventh Circuit Holds That Sereboff Supports Disability Carrier’s Counterclaim

Although Standard’s plan does not use the word “discretion,” it uses a variety of equivalent terms that convey the same meaning. See supra (”full and exclusive authority to control and manage, . . . to administer, . . . and to interpret and to resolve all questions arising in its administration, interpretation, and application”; “[t]he …

:: Seventh Circuit Holds That Sereboff Supports Disability Carrier’s Counterclaim Read More »