Medical Benefit Claims

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Good morning, ERISA Watchers!  Hope you all survived the Mercury retrograde, which I’m convinced brought about the last two terrible notable decisions out of the Fourth Circuit.  This week I want to take a moment to highlight two decisions from the Sixth Circuit Court of Appeals.  Unfortunately, these opinions are not great for plan participants either, except for a little nugget from Springer v. Cleveland Clinic Employee Health Plan Total Care, No. 17-4181, __F.3d__, 2018 WL 3849376 (6th Cir. Aug. 14, 2018).  

In Springer, the plan administrator denied the plan participant’s claim for coverage for air ambulance transportation because he did not seek preauthorization.  On the upside, the Sixth Circuit affirmed the district court’s determination that the plaintiff has standing to bring his claim despite the failure to allege a financial loss.  The court noted that “[e]very circuit court to consider this issue agrees that a plaintiff in Springer’s shoes does not need to suffer financial loss.
Continue Reading Sixth Circuit Joins Sister Circuits: Denial of Plan Benefits Confers Standing Even If Not Billed Directly for Medical Services

This week’s notable decision is out of the Ninth Circuit Court of Appeals in the matter of Danny P. v. Catholic Health Initiatives, No. 16-35609, __F.3d__, 2018 WL 2709733 (9th Cir. June 6, 2018).  Plaintiffs brought suit against Catholic Health Initiatives and Catholic Health Initiatives Medical Plan–Blue Cross Blue Shield (collectively “the Plan”) for denying the cost of Nicole B’s inpatient stay in Island View Residential Treatment Center, a residential mental health treatment facility.  The district court granted summary judgment in favor of the Plan.  It found that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, codified at 29 U.S.C. § 1185a (“Parity Act”) did not require that the Plan’s coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities. 
Continue Reading Ninth Circuit Holds that Parity Act Requires Health Plan to Also Provide Room and Board Coverage for Residential Treatment Facilities

This week’s notable decision is from the putative class action case, Moura v. Kaiser Foundation Health Plan, Inc., No. C 17-02475 JSW, 2018 WL 1569812 (N.D. Cal. Mar. 30, 2018), which challenges Kaiser’s alleged pattern and practice of denying treatment for eating disorders in violation of ERISA and the California and Federal Health Parity Acts.  The court previously granted Kaiser’s motion to dismiss the original complaint on the basis that Moura failed to allege that he exhausted his administrative remedies for the denial of his claim for treatment of anorexia nervosa.  Moura then filed a first amended complaint alleging only a claim pursuant to 29 U.S.C. Section 1132(a)(3) for breach of fiduciary duty against the plan administrators. 
Continue Reading Kaiser Must Defend ERISA Breach of Fiduciary Duty Claim Challenging Its Treatment of Eating Disorders