Practice Tips

: : May A Grant of Authority As An Attorney In Fact On A Health Care Provider Confer Standing?

“In 2018, the Third Circuit held in American Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield, that “anti-assignment clauses in ERISA-governed health insurance plans as a general matter are enforceable.” 890 F.3d 445, 453 (3d. Cir. 2018). Here, Patient’s plan contains an anti-assignment clause. Plaintiff agrees with Defendants that anti-assignment clauses are “valid …

: : May A Grant of Authority As An Attorney In Fact On A Health Care Provider Confer Standing? Read More »

: : Plan Prevails On Participant’s Challenge to Recoupment By Administrative Offset Of Benefit Payments

The Court is obliged to dismiss this action because Plaintiff has ultimately pleaded himself out of court. . . . Notably, Defendant has not pleaded that Plaintiff, in seeking to recoup and recouping the overpayments, violated either ERISA or the Plan.Hesse v. Case New Holland Indus. (E.D. Wis. 2021) Recovering plan overpayments will frequently lead …

: : Plan Prevails On Participant’s Challenge to Recoupment By Administrative Offset Of Benefit Payments Read More »

: : GAO Report Offers Insights Into EBSA Investigations & Enforcement Activities

“EBSA regional offices conduct investigations of retirement and health plans to detect and correct violations of Title I of ERISA and related criminal laws. EBSA investigators identified 4,273 violations in the 1,411 investigations closed in fiscal year 2020. This included 3,776 retirement plan violations from 1,056 closed investigations and 377 health plan violations from 288 …

: : GAO Report Offers Insights Into EBSA Investigations & Enforcement Activities Read More »

: : Primer Provider Reimbursement Pleading To Avoid Motion To Dismiss

“Before the Court is Defendants Cigna Healthcare Inc., Cigna Health and Life Insurance Co., Connecticut General Life Insurance Co., and Cigna Healthcare of Arizona’s (collectively, “Cigna”) Motion to Dismiss. In October 2018, PSCC received a letter from Cigna that it had “conducted an internal audit and determined that PSCC had damaged Cigna in an amount …

: : Primer Provider Reimbursement Pleading To Avoid Motion To Dismiss Read More »

: : 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., …

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

:: Should ERISA Attorneys Be Held Liable For Aiding & Abetting A Fiduciary Breach?

May an attorney be held liable for aiding and abetting a fiduciary breach? A recent law review article raises the issue and advocates the view. The article isn’t written for an ERISA audience, but it suggests the idea – should attorneys be held liable for advising ERISA fiduciaries on actions that are found to constitute …

:: Should ERISA Attorneys Be Held Liable For Aiding & Abetting A Fiduciary Breach? Read More »

:: Disclaimer Shields Claims Administrator From Mispresentation Claims

Tenet alleges that it provided approximately $ 241,000 worth of medical services to Sylvester based on UniCare’s representation that Sylvester was covered under the Plan. . . .  Pursuant to the Managed Care Agreement, UniCare paid Tenet $ 132,827.34, the negotiated payment under the agreement, on July 27, 2005.  On August 5, 2005, Sheltering Arms …

:: Disclaimer Shields Claims Administrator From Mispresentation Claims Read More »

:: Sixth Circuit Opinions Applying Estoppel In ERISA Cases – An Anthology

Estoppel under ERISA is an equitable doctrine of the federal common law of contracts designed to enforce ERISA and the agreements made under it. Armistead v. Vernitron, 944 F.3d 1287, 1298 (6th Cir. 1991). There are five elements to an estoppel claim under ERISA: (1) a representation of fact made with gross negligence or fraudulent …

:: Sixth Circuit Opinions Applying Estoppel In ERISA Cases – An Anthology Read More »