Medical Benefit Claims

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Happy Presidents’ Day, ERISA Watchers!  Many of us technically have the day off today, which just means catching up on the backlog of work while the stream of emails is lighter (unless you’re my opposing counsel).  And, hopefully this is your favorite Monday morning email.  

This week’s notable decision is a short unpublished decision from the Sixth Circuit, Zino, et al. v. Whirlpool Corp., et al., No. 17-3851, __F.App’x__, 2019 WL 644883 (6th Cir. Feb. 15, 2019). The Sixth Circuit reversed the district court’s (N.D. Ohio) determination that the CBAs at issue vested the Hoover Company retirees with unalterable lifetime healthcare benefits.  The majority found that the CBA’s general durational clauses that state when the agreements end also control when healthcare benefits end.
Continue Reading Another Loss for Retirees: Sixth Circuit Holds No Lifetime Healthcare Coverage

This week’s notable decision is Rittinger v. Healthy All. Life Ins. Co., No. 17-20646, __F.3d__, 2019 WL 391771 (5th Cir. Jan. 31, 2019), a case involving the denial of coverage for bariatric surgery and follow-up surgery for complications.  The Fifth Circuit reversed the district court’s determination in favor of Rittinger and found that Anthem did not abuse its discretion in the handling of Rittinger’s appeals.  This is yet another case where the standard of review makes all the difference.  As the court explained, “[A]lthough not the paragon of procedural propriety, Anthem satisfied the very low, very deferential abuse-of-discretion standard.”  Because the court found that Rittinger is not entitled to any damages, the court dismissed her cross-appeal to determine the exact dollar amount of damages she is owed.    
Continue Reading Fifth Circuit Holds that Anthem Did Not Abuse Its Discretion in Denying Coverage for Bariatric Surgery

Good morning, ERISA Watchers!  Last week was quite a busy week with notable Circuit Court decisions.  In Hager v. DBG Partners, Inc., No. 17-11147, __F.3d__, 2018 WL 4258968 (5th Cir. Sept. 6, 2018), the court addressed an issue of first impression for the Fifth Circuit concerning the availability of a remedy for a COBRA notice violation.  The court determined that payment of all medical expenses is compensatory damages which is not available under ERISA Section 502(a)(3).  But, a penalty is available under Section 502(c)(1) and the court could “discern no barrier to the court awarding the amount of [the participant’s] medical expenses as a penalty.”  The court remanded the case to the district court to determine whether to award a penalty and the amount of such penalty.
Continue Reading Circuit Courts Tackle Issues of First Impression and Preemption