Articles Posted in ERISA

Attorneys handling ERISA claims will tell you the difficulties of ERISA claims and the ways to make sure those difficulties do not ruin the claim. A 2014, 5th Circuit Court of Appeals case needs to be read to see ways of avoiding some of the difficulties. The style of the case is, Hollingshead v. Aetna Health Inc.

This case reached the 5th Circuit Court of Appeals after the U.S. District Court dismissed the plaintiff’s putative class action complaint for failure to state a claim for violations of the Employee Retirement Income Security Act.

Through his employer, plaintiff Joe Hollingshead participated in a self-funded ERISA benefit plan with Aetna as the Plain’s claims administrator. The Plan included a number of coordination of benefits provisions, indicating how benefits would be paid in the event that Plan participants had medical coverage from more than one source. Under the Plan, certain sources of insurance coverage were considered “primary,” while other sources were considered “secondary.” In the event that the Plan was secondary, its benefits were to be determined after those of the primary plan. Practically, this meant that benefits under the Plan could be reduced. In fact, the Plan contained a provision explaining that failure to provide Aetna with necessary information and documentation could cause payment of benefits to be delayed or even denied. Under the Plan, no-fault auto insurance was considered primary.

ERISA lawyers will be watching this United States Supreme Court case. It is styled Montanile v. National Elevator Industry Health Benefit Plan. The Insurance Journal published a story discussing this case. The story is titled, Supreme Court in Bind Over Insurer’s Right to Insured’s Damages Money.

Which do the conservative justices hate more: personal-injury lawyers or interpreting a law loosely to expand the power of lower courts? That question was to be on the table Monday at the U.S. Supreme Court. The justices are hearing oral argument in a potentially important case about whether you have to pay back your insurance company for medical bills after you’ve sued and recovered from the person who injured you in the first place.

Montanile v. National Elevator Industry Health Benefit Plan has all the marks of a case only lawyers could love. It involves insurance, money, a drunken driver and what may arguably be the most complicated statute in the entire U.S. Code, the Employee Retirement and Income Security Act of 1974, known as ERISA.

ERISA lawyers need to read the 2015 opinion from the U.S. District Court, Houston Division. It is styled, Michael Nall, et al, v. BNSF Railway Company, et al.

Nall was an employee of BNSF Railway. He alleged that based on his employment he was entitled to receive certain benefits under the plan provided by BNSF. This benefit plan was an ERISA benefit plan.

Nall was diagnosed with Parkinson’s disease and was having many problems that are discussed in the opinion. The relevant issue in this case is that while Nall was out on disability in 2013, he received his annual enrollment package regarding his 2014 coverage. According to this enrollment package, Nall did not need to submit anything in order to continue coverage for 2014. Nall relied on this notification and assumed that his benefits would continue on just as in the past. After getting some further treatment, Nall received a bill from one of his doctors and then learned that his benefits had ended.

The above question is always being asked by insurance lawyers when someone sees them about an insurance claim. Whether a claim is covered by ERISA or not, makes a huge difference in how the claim is handled. A little insight into whether a claim is an ERISA claim or not is gleamed from a 2015, Fifth Circuit case. It is styled, Kelsey-Seybold Medical Group PA v. Great-West Healthcare of Texas, Incorporated.

Kelsey sued Great-West in Texas state court, alleging that Great-West had not paid the contractually required rate for medical services that Kelsey had provided to members of Great-West-affiliated healthcare plans. Great-West removed the case to federal court on the ground that Kelsey’s claims were completely preempted by ERISA. Kelsey moved to remand on the basis that its claims were not completely preempted and, therefore, the district court lacked subject matter jurisdiction. The district court declared the claims preempted and entered a take-nothing judgment in favor of Great-West. To determine whether a claim is completely preempted by ERISA, the Court applies the two-part test set forth in the case Aetna Health Inc. v. Davila: a claim is completely preempted if

(1) the claimant “could have brought his claim under ERISA § 502(a)(1)(B),” and

Lawyers handling ERISA claims will enjoy reading this 2015, Fifth Circuit opinion. It is styled, Rebecca Hamsher v. North Cypress Medical Center Operating Company, Limited.

North Cypress provides health insurance to its employees through its self-funded Employee Benefit Plan (the “Plan”). As with many insurers, North Cypress must pre-approve certain medical treatments. If pre-approval is required, but not received, North Cypress may reduce its payment to its beneficiaries, or deny reimbursement altogether.

The Plan has two types of pre-approval. The first is called “precertification,” and it applies to all “hospitalizations” and “inpatient mental disorder/substance use disorder treatments.” To precertify, the covered person or a family member must contact North Cypress’s medical management subcontractor, Meritain Health Medical Management, at least 48 hours before treatment is to begin. Meritain will then determine how many days of treatment are medically necessary. That said, a failure to precertify is not an absolute bar to reimbursement. “If a Covered Person does not obtain precertification, as required for certain benefits under the Plan, eligible expenses will be reduced by $500.”

Parker County ERISA attorneys know the two documents needed to be reviewed in an ERISA case are the Certificate of Coverage (COC) and the “summary plan description.”

The United States Court of Appeals for the Fifth Circuit issued an ERISA opinion in 2012, that is relevant to these documents. It is styled, Nancy Koehler v Aetna Health, Inc.

The case is an appeal from an adverse summary judgment against Koehler. Aetna refused to reimburse Koehler for an out of network specialist who had been referred by an in network physician. Aetna denied based on the referral not being pre-authorized by Aetna.

Fort Worth ERISA attorneys already know that an ERISA case is not entitled to a jury trial. The U.S. District Court For The Southern District Of Texas Houston Division issued an opinion wherein that issue was a point of contention. The style of the case is Lucinda Francis v. South Central Houston Action Council, Inc. D/B/A Central Care Community Health Center.

Francis alleges that on July 25, 2013, Central Care terminated her employment. Francis filed her Complaint alleging that Central Care violated section 510 of ERISA when it terminated her employment soon after she elected to enroll in Central Care’s employee health insurance program because Central Care wanted to avoid covering Francis’s benefit plan expenses. Francis also alleges that Central Care’s motivation for terminating her employment violated the Age Discrimination in Employment Act and Title VII of the Civil Rights Act of 1964. She requested a trial by jury on all of her claims. In Defendant’s Answer Central Care alleged that Francis’s termination was based on Francis’s insubordination in failing to follow proper policies and procedures with regard to clocking in and out. Central Care moved to strike Francis’s ERISA claim, arguing that Francis lacks standing to bring an ERISA claim and that ERISA claims are not triable by a jury.

Central Care argues that Francis’s ERISA claim should be stricken based on lack of statutory standing because Francis does not qualify as a “participant” in Central Care’s benefit plan. Francis responds that a motion for summary judgment, rather than a Rule 12(f) motion to strike under the Federal Rules of Civil Procedure, is the appropriate vehicle for dismissal of an ERISA claim based on lack of statutory standing. Central Care responds that its Motion to Strike was not raised pursuant to Rule 12(f), and that Francis’s ERISA claim should be stricken because Francis lacks standing and the court therefore lacks subject-matter jurisdiction.

ERISA attorneys need to read a recent opinion from the U.S. District Court for the Western District of Pennsylvania. It is styled, US Airways, Inc. v. James E McCutchen and Rosen, Louik & Perry, P.C.

The legal journey of this case is semi-complicated. What is relevant is that the employer, US Airways did not produce a copy of the ERISA Plan until US Airways agreed to produce the Plan during a meeting requested by the Office of the Solicitor General of the United States and the Department of Labor. The purpose of the meeting was to assist the Government’s attorneys in deciding whether to file an amicus curiae brief in the United States Supreme Court.

US Airways produced the actual Plan with numerous amendments, and Defendants contend that they then learned for the very first time that the Plan differed in material respects from the SPD, neither providing for a right to reimbursement nor mentioning the right to reimbursement from a recovery from one’s own insurance policy, i.e., underinsured motorist benefits.