Stop Loss

: : Employer Sues Stop Loss Carrier and Express Scripts Alleging Fiduciary and Contractual Breach

“Express Scripts moves for summary judgment on Henkel’s claim for breach of fiduciary duty. Henkel alleges that Express Scripts breached its fiduciary duty not only by failing to adhere to the coverage criteria in the prior authorization policies but also by approving the subsequent claims. . . . Here, a reasonable jury could conclude that, …

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:: 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” …

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:: Stop Loss Carrier Averts ERISA Preemption In Dispute Over “Fronted” Claims Reimbursement

More specifically, the sole issue we decide in this appeal is whether ERISA preempts a state law breach of contract claim and an alternatively pled state law unjust enrichment claim brought by a third-party company hired to perform only non-discretionary administrative services, under the self-funded portion of an employee health care benefit plan covered by …

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