:: HMO Loses Third Party Beneficiary Contract Dispute With Health Care Providers

HOI’s own records admitted into evidence at trial demonstrated that HOI (a) sought to save itself $4.1 million annually by discontinuing these payments to clinical pathologists, (b) anticipated that litigation would follow that action, and (c) recognized that Medicare and Medicaid had established payment amounts that included the disputed component for the pathologists’ supervision and …

:: HMO Loses Third Party Beneficiary Contract Dispute With Health Care Providers Read More »

:: District Court Opinion On PBM Disclosure Law Vacated

The plaintiff-the Pharmaceutical Care Management Association-is a national trade organization representing pharmacy benefit managers. Pharmacy benefit managers act as “middlemen” hired by health benefit providers (such as employers, health maintenance organizations, and public and private health plans) “to provide prescription drug benefit administration and management services.” One important role of a pharmacy benefit manager is …

:: District Court Opinion On PBM Disclosure Law Vacated Read More »

:: Update On DOL Audit Profiling & Investigational Focus

Aaron Juckett,One Stop ESOP Blog, provides an overview of key points noted during an April 15, 2008 presentation by Paul Windsor, an investigator from the Employee Benefits Security Administration (EBSA) of the Department of Labor (DOL). The program title, What to Expect from an Employee Benefits Security Administration Investigation, is undoubtedly an attention-getter. The program …

:: Update On DOL Audit Profiling & Investigational Focus Read More »

:: Eleventh Circuit Joins Tenth On Production Of “Appeal-Level” Medical Reviews

Glazer argues that she was not provided a “full and fair review” of the denial of her request for benefits as required by ERISA. 29 U.S.C. § 1133(2). If benefits are denied, section 1133 requires the plan administrator, “[i]n accordance with regulations of the Secretary,” to provide a “full and fair review … of the …

:: Eleventh Circuit Joins Tenth On Production Of “Appeal-Level” Medical Reviews Read More »

:: Oral Argument In MetLife v. Glenn – Daunting Hypotheticals Illustrate Actual Ambiguities

Consistent with established principles of trust law, we hold that a denial of benefits challenged under 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan. . . . Thus, for …

:: Oral Argument In MetLife v. Glenn – Daunting Hypotheticals Illustrate Actual Ambiguities Read More »

:: Postscript To MetLife v. Glenn

This case looks like it is going the way of most remedy cases – a debate between the literalist and remedialists on the court. The literalists (Roberts, Alito, Scalia, and Thomas) think that the statutory provision is clear and there shouldn’t be a separate standard of review for conflicts. The remedialists (Stevens, Souter, Breyer, and …

:: Postscript To MetLife v. Glenn Read More »

:: Fourth Circuit Rejects Validity Of Assignments Taken In Claims Settlement

Although we have never addressed the question of derivative standing for ERISA benefits, our sister circuits have consistently recognized such standing when based on the valid assignment of ERISA health and welfare benefits by participants and beneficiaries. . . . Thus, it may be that in the proper case assignees other than health care providers …

:: Fourth Circuit Rejects Validity Of Assignments Taken In Claims Settlement Read More »

:: Failure To Furnish SPD Can Lead To Loss Of Deferential Standard Of Review

Although Lumbermens has shown that the Summary Plan Description (“SPD”) 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 Marietta Long Term Disability Income Plan, 244 F.3d 1109, 1112 (9th Cir.2001), it has failed to show that it properly …

:: Failure To Furnish SPD Can Lead To Loss Of Deferential Standard Of Review Read More »

:: Of The Many Troubles That Attend Worker Misclassification – Another Item For The List

Janell Grenier recently noted the employee benefit troubles that can result from misclassification of workers. The occasion of the comment was a recent article in the L.A. Times, “Independent Contractor Status Scrutinized.” In addition to the problems of having insurance coverage defeated based upon “employee” definitions, inadvertently promising benefits to those you did not intend, …

:: Of The Many Troubles That Attend Worker Misclassification – Another Item For The List Read More »

:: Failure To Furnish SPD Can Lead To Loss Of Deferential Standard Of Review

Although Lumbermens has shown that the Summary Plan Description (“SPD”) 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 Marietta Long Term Disability Income Plan, 244 F.3d 1109, 1112 (9th Cir.2001), it has failed to show that it properly …

:: Failure To Furnish SPD Can Lead To Loss Of Deferential Standard Of Review Read More »