Justia Insurance Law Opinion Summaries

Both of the injured employees in these cases, Charles Morris and Charles Poole, were treated at the Lafayette Bone & Joint Clinic (“LB&J”); Morris was treated by Dr. Louis Blanda and Poole by Dr. John Cobb. Louisiana United Business SIF (“LUBA”), sent letters to LB&J and its doctors stating that LUBA would no longer pay for prescription medications directly dispensed by LB&J and directing LB&J doctors to issue future prescriptions for the instant injured employees that could be filled at local retail pharmacies. Despite these notices and subsequent denials of requests for reimbursement of dispensed prescription medications, LB&J doctors continued to dispense prescription medications to these injured employee patients throughout 2008 and to submit requests for reimbursement to LUBA. LUBA declined payment for these requests, citing its prior notice. LB&J and the treating physicians thereafter filed disputed claim forms with the Office of Workers’ Compensation (OWC), seeking to recover the cost of the medications dispensed, along with penalties and attorney fees. Following a joint trial in these two cases, the OWC judge ruled that the plaintiff/health care providers’ recovery for medications dispensed after the 2008 notice were nonemergency treatment dispensed without consent of the payor. Further, the OWC judge found that no penalties or attorney fees were warranted because LUBA had clearly advised the plaintiff/health care providers that no further reimbursement would be made for prescription medications dispensed by LB&J doctors after the date of the notice. The plaintiff/health care providers appealed, seeking an increase in the amount awarded and an award of penalties and attorney fees. The Louisiana Supreme Court granted writs to review the appellate court decisions, which awarded unreimbursed prescription medication costs beyond the $750 limitation set forth in LSA-R.S. 23:1142(B) and awarded penalties and attorney fees. The Court reversed the appellate court's modification of the amount awarded by the OWC, and affirmed in part, the decision to award penalties and attorney fees. View "LaFayette Bone & Joint Clinic v. Louisiana United Business SIF" on Justia Law

After Siasmorn Gopal was admitted to the emergency room at Kaiser Foundation Hospitals and died after she was transferred to another hospital, Gopal's husband and the trustee of her estate filed suit alleging that defendants violated California law. Plaintiffs alleged that Kaiser Hospitals, SCPMG, and Health Plan treated Gopal differently than they would have treated a member and that the different treatment caused her death. The court affirmed the trial court's rejection of plaintiffs' enterprise theory of liability. The court concluded that there is nothing inequitable in requiring plaintiffs to look to Kaiser Hospitals and SCPMG - the providers at issue - for compensation for their claims. Thus, plaintiffs are not without recourse or remedy. The court noted that the fact that health care providers, and not health plans, are subject to the Medical Injury Compensation Reform Act of 1975 (MICRA), Civ. Code, 3333.2, is not an inequitable result, but a public policy determination made by the Legislature. Accordingly, the court affirmed the judgment. View "Gopal v. Kaiser Found. Health Plan" on Justia Law

Luz Herrera was injured in an accident while operating a vehicle insured by Hanover Insurance Company, a no-fault insurer. Herrera also had private health insurance through Aetna Health Plan. Herrera received medical treatment for her injuries, and the medical providers submitted some of their bills directly to Aetna, who paid the bills. Aetna subsequently sought reimbursement from Hanover, but Hanover did not respond. Meanwhile, Aetna filed a lien against Herrera for reimbursement. Herrera then resubmitted all of the medical bills to Hanover and assigned her rights against Hanover to Aetna. Aetna then commenced this action against Hanover seeking reimbursement for the medical bills it paid on Herrera’s behalf. Supreme Court dismissed the complaint, concluding (1) because Aetna was not a “health care provider” under the no-fault statute, it was not entitled to direct payment of no-fault benefits; (2) Aetna was neither in privity of contract with Hanover nor an intended third-party beneficiary of Hanover’s contract with Herrera; and (3) Aetna could not maintain a subrogation claim against Hanover. The Appellate Division affirmed. The Court of Appeals affirmed, holding that New York’s Comprehensive Motor Vehicle Reparations Act statutory law and regulatory scheme does not contemplate reimbursement to a health insurer, as opposed to a health care provider. View "Aetna Health Plans v. Hanover Ins. Co." on Justia Law

Blue Cross controls more than 60% of the Michigan commercial health insurance market; its patients are more profitable for hospitals than are patients insured by Medicare or Medicaid. BC enjoys “extraordinary market power.” The Justice Department (DOJ) claimed that BC used that power to require MFN agreements: BC would raise its reimbursement rates for services, if a hospital agreed to charge other commercial insurers rates at least as high as charged to BC. BC obtained MFN agreements with 40 hospitals and MFN-plus agreements with 22 hospital systems. Under MFN-plus, the greater the spread between BC's rates and the minimum rates for other insurers, the higher the rates that BC would pay. Class actions, (consolidated) followed the government’s complaint, alleging damages of more than $13.7 billion, and seeking treble damages under the Sherman Act, 15 U.S.C 15. In 2013, Michigan banned MFN clauses; DOJ dismissed its suit. During discovery in the private actions, plaintiffs hired an antitrust expert, Leitzinger. BC moved to exclude Leitzinger’s report and testimony. Materials relating to that motion and to class certification were filed under seal, although the report does not discuss patient information. BC agreed to pay $30 million, about one-quarter of Leitzinger's estimate, into a settlement fund and not to oppose requests for fees, costs, and named-plaintiff “incentive awards,” within specified limits. After these deductions, $14,661,560 would be allocated among three-to-seven-million class members. Class members who sought to examine the court record or the bases for the settlement found that most key documents were heavily redacted or sealed. The court approved the settlement and denied the objecting class members’ motion to intervene. The Seventh Circuit vacated, stating that the court compounded its error in sealing the documents when it approved the settlement without meaningful scrutiny of its fairness to unnamed class members . View "Shane Group, Inc. v. Blue Cross Blue Shield of Mich." on Justia Law

Employers must cover certain contraceptives as part of their health plans unless the employer submits a form to their insurer or to the federal government, stating that they object on religious grounds to providing contraceptive coverage. The plaintiff-employers alleged that submitting this notice substantially burdened the exercise of their religion, in violation of the Religious Freedom Restoration Act of 1993,, 42 U.S.C. 2000bb. In supplemental briefing, the parties acknowledged that contraceptive coverage could be provided to employees, through insurance companies, without such notice. Plaintiffs “need to do nothing more than contract for a plan that does not include coverage for some or all forms of contraception,” and employees could receive cost-free contraceptive coverage from the same insurance company, seamlessly, with the rest of their coverage. Based on these stipulations, the Supreme Court vacated the judgments below and remanded to determine an approach that will accommodate the employers’ religious exercise while ensuring that women covered by their health plans “receive full and equal health coverage, including contraceptive coverage.” The Court did not decide whether the employers’ religious exercise has been substantially burdened, whether the government has a compelling interest, or whether the current regulations are the least restrictive means of serving that interest. View "Zubik v. Burwell" on Justia Law

Plaintiffs, two individual psychiatrists and three professional associations of psychiatrists, filed suit against defendants, four health‐insurance companies, alleging that the health insurers’ reimbursement practices discriminate against patients with mental health and substance use disorders in violation of the Mental Health Parity and Addition Equity Act of 2008 (MHPAEA), 29 U.S.C. 1185(a), and the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001-1461. The court concluded that, because the psychiatrists are not among those expressly authorized to sue, they lack a cause of action under ERISA. The court also concluded that the association plaintiffs lack constitutional standing to pursue their respective ERISA and MHPAEA claims because their members lack standing. Accordingly, the court affirmed the judgment. View "Am. Psychiatric Ass’n v. Anthem Health Plans, Inc." on Justia Law

A group of New York-based third party payor health insurers (“TPPs”) that provided prescription drug benefits to union members appealed a Superior Court judgment dismissing with prejudice their second amended complaint. At issue were claims brought by the TPPs under various state consumer fraud laws against AstraZeneca Pharmaceuticals LP, and Zeneca Inc. (collectively “AstraZeneca”). The TPPs alleged that AstraZeneca falsely advertised its more expensive patented prescription drug "Nexium" as superior to the less expensive generic drug "Prilosec," causing the TPPs to overpay for Nexium when generic Prilosec would have sufficed. After conducting an extensive choice of law analysis, the Superior Court determined that New York law controlled the TPPs’ claims. The court then held that the TPPs failed to state a claim under New York’s consumer fraud statute for failure to allege legally sufficient causation. The TPPs appealed, arguing the Superior Court's choice of law analysis was flawed, and that the Superior Court's causation analysis was equally flawed. After a careful review of the record on appeal, the Delaware Supreme Court affirmed the ultimate judgment of the Superior Court, finding it not necessary to discuss whether the Superior Court correctly analyzed the choice of law issue, because under either state consumer fraud statute the TPPs could not recover damages as a matter of law. View "Teamsters Local 237 Welfare Fund, et al. v. AstraZeneca Pharmaceuticals LP" on Justia Law

The Authority faced a funding shortfall for at least the period immediately after its opening in 2014. To cover the shortfall, the Authority, with emergency authorization from the District’s Council, levied a charge on all insurance policies above a certain premium threshold sold by health carriers in the District. American Council raised statutory and constitutional challenges to that charge and the district court rejected Council's arguments, dismissing the complaint for failure to state a claim. The court agreed with the District that the district court lacked jurisdiction to hear this case because the charge levied by the Authority was a tax rather than a fee. Therefore, the court vacated the district court's judgment for lack of jurisdiction and remanded with instructions to dismiss the case for lack of jurisdiction because the assessment is a tax. View "American Council of Life Ins. v. District of Columbia Health" on Justia Law

Vermont law requires certain entities, including health insurers, to report payments and other information relating to health care claims and services for compilation in a state health care database. Liberty Mutual’s health plan, which provides benefits in all 50 states, is an “employee welfare benefit plan” under the Employee Retirement Income Security Act (ERISA); its third-party administrator, Blue Cross, is subject to the statute. Concerned that the disclosure of confidential information might violate its fiduciary duties, the Plan instructed Blue Cross not to comply and sought a declaration that ERISA preempts application of Vermont’s statute. The Second Circuit reversed summary judgment in favor of the state. The Supreme Court affirmed. ERISA expressly preempts “any and all State laws insofar as they may now or hereafter relate to any employee benefit plan,” 29 U.S.C. 1144(a) and, therefore, preempts a state law that has an impermissible “connection with” ERISA plans. ERISA mandates certain oversight systems and other standard procedures; Vermont’s law also governs plan reporting, disclosure, and recordkeeping. Preemption is necessary to prevent multiple jurisdictions from imposing differing, or even parallel, regulations, creating wasteful administrative costs and threatening to subject plans to wide-ranging liability. ERISA’s uniform rule design makes clear that the Secretary of Labor, not the states, decides whether to exempt plans from ERISA reporting requirements or to require ERISA plans to report data such as sought by Vermont. View "Gobeille v. Liberty Mut. Ins. Co." on Justia Law

Chapter 1301 of the Texas Insurance Code requires healthcare insurers to make coverage determinations and pay claims made by preferred healthcare providers within a specified time or face penalties. HCSC filed suit seeking a declaratory judgment against Methodist, seeking a declaration that Chapter 1301 does not apply to HCSC as the administrator of particular health plans, and the Federal Employee Health Benefits Act of 1959 (FEHBA), 5 U.S.C. 8901, et seq., preempts application of the statute to its administration of claims under the Federal Employees Health Benefits Program (FEHBP). The district court granted summary judgment to HCSC. The court held that Chapter 1301 is not applicable to BCBSTX’s activities as administrator of the self-funded plans or state government plans, nor to those activities that it performs as administrator of claims under the BlueCard program. The court also held that FEHBA preempts Chapter 1301’s application to the claims processed by BCBSTX under FEHBP plans. Accordingly, the court affirmed the judgment. View "Health Care Serv. Corp. v. Methodist Hospitals" on Justia Law