AGG Talks: Healthcare Insights Podcast - Episode 4: What to Do When Insurance Companies Deny Behavioral Health Claims
This month’s Friday Five addresses cases covering ERISA preemption, the viability of a claim for benefits where the claimant alleges to have not received notice of a prior claim denial, an affirmance by the Circuit Court of a...more
This month’s Friday Five covers an appellate ruling on a complicated case raising both state and federal claims, an instance of procedural improprieties in the administrative review process informing the court’s substantive...more
When the same health plan administrator both administers a benefit plan and pays the benefits due under the plan, it is considered by courts to have a structural conflict of interest. That conflict of interest is not...more
The United States Court of Appeals recently shed light on when—and under what conditions—a plaintiff may seek a monetary recovery under § 502(a)(3) of the Employee Retirement Income Security Act (ERISA). Section 502(a)(3)...more
Last month, a three-judge panel in the Ninth Circuit reversed the Northern District of California’s ruling in Wit v. United Behavioral Health. In Wit, the district court ruled that United Behavioral Health (“UBH”) breached...more
In DeBold v. Liberty Life Assur. Co. of Bos., 2021 U.S. Dist. LEXIS 120153 (D. Mass, June 28, 2021), a district court held that an ERISA plan administrator could reduce an insured's monthly long-term disability (LTD) benefit...more
This week, this Ninth Circuit once again issued a number of opinions arising from the employment relationship. Here, we focus on two of particular interest. In the first, the Court sought to unravel whether an emergency room...more
In Western v. Unum Life Insurance Company of America, 798 F.App'x 154, 2020 U.S. App. LEXIS 8362 (9th Cir. March 17, 2020), the Ninth Circuit affirmed Unum Life's determination that an aerospace engineer diagnosed with...more
In Josef K. v. California Physicians’ Service, No. 18-cv-06385-YGR (U.S. District Court for the Northern District of California, June 3, 2019), Judge Yvonne Gonzalez Rogers concluded that an independent medical review (IMR)...more
Earlier this month, on March 5, 2019, the United States District Court in the Northern District of California filed its 106-page Findings of Fact and Conclusions of Law in the class action Wit v. United Behavioral Health...more
On July 3, 2018, a District Court in Alabama upheld, on reconsideration, its initial decision to dismiss a plaintiff’s breach of fiduciary duty claim under ERISA § 502(a)(3), 29 U.S.C. § 1132(a)(3), finding that ERISA §...more
The stories of an employer and a long-term disability insurer and claims fiduciary for an ERISA plan, defendants in two recent cases, ring so true. In the first case, the insurer was designated as claims fiduciary for an...more
Over the past couple years, more and more of my clients with self-funded plans have received letters from out-of-network providers appealing denied claims. The letters are usually 20 to 30 pages long, not very specific, and...more
In late August the U.S. Court of Appeals for the Second Circuit reinstated a lawsuit by a physician association against a third-party plan administrator. The case against UnitedHealth Group and related entities (United) had...more
On March 5, 2015, the U.S. Court of Appeals for the Sixth Circuit, sitting en banc in the matter of Rochow v. Life Insurance Company of North America, 2015 WL 925794 (6th Cir. Mar. 5, 2015), reversed the finding of a prior...more
The U.S. Court of Appeals for the Sixth Circuit has affirmed an unusually large award of $3.8 million in a case involving the denial of long-term disability benefits. In Rochow v. Life Insurance Company of North America, No....more
Kenseth v. Dean Health Plan, Inc., represents a significant departure from the decades of law prior to Cigna v. Amara holding that employees could not recover for misrepresentations by employers over benefit coverage if the...more