Justia Insurance Law Opinion Summaries

Annex, Stuart Lind, and Tom Janas filed suit challenging HHS' contraceptive mandate under the Religioous Freedom Restoration Act (RFRA), 42 U.S.C. 2000bb-1(a). Lind, a controlling shareholder of Annex, opposed insurance coverage of contraceptives for Annex's employees. The district court denied Annex and Lind's motion for a preliminary injunction respecting the contraceptive mandate's enforcement. The court concluded that Janas lacks standing to appeal because he did not join the preliminary injunction motion which forms the basis of the appeal; the mandate does not apply to Annex because Annex has fewer than fifty full-time employees and has no government-imposed obligation to offer health insurance of any kind; the only alleged injury is that independent third parties - private health insurance companies not involved in this case - are unable to sell Annex a health insurance plan that excludes healthcare inconsistent with Lind's religious relief; and, ultimately, it is unclear whether Annex's alleged injury is caused by the government defendants and redressable by the federal courts. Accordingly, the court vacated the district court's denial and remanded for the district court to conduct more fact-finding to determine whether subject matter jurisdiction exists. View "Annex Medical, Inc., et al. v. Sebelius, et al." on Justia Law

Department of Health and Human Services (HHS) regulations implementing the 2010 Patient Protection and Affordable Care Act (ACA) require that employers’ group health plans furnish preventive care and screenings for women without cost sharing requirements, 42 U.S.C. 300gg–13(a)(4). Nonexempt employers must provide coverage for 20 FDA-approved contraceptive methods, including four that may have the effect of preventing a fertilized egg from developing. Religious employers, such as churches, are exempt from the contraceptive mandate. HHS has effectively exempted religious nonprofit organizations; an insurer must exclude contraceptive coverage from such an employer’s plan and provide participants with separate payments for contraceptive services. Closely held for-profit corporations sought an injunction under the 1993 Religious Freedom Restoration Act (RFRA), which prohibits the government from substantially burdening a person’s exercise of religion even by a rule of general applicability unless it demonstrates that imposing the burden is the least restrictive means of furthering a compelling governmental interest, 42 U.S.C. 2000bb–1(a), (b). As amended by the Religious Land Use and Institutionalized Persons Act of 2000 (RLUIPA), RFRA covers “any exercise of religion, whether or not compelled by, or central to, a system of religious belief.” The Third Circuit held that a for-profit corporation could not “engage in religious exercise” under RFRA and that the mandate imposed no requirements on corporate owners in their personal capacity. The Tenth Circuit held that the businesses are “persons” under RFRA; that the contraceptive mandate substantially burdened their religious exercise; and that HHS had not demonstrated that the mandate was the “least restrictive means” of furthering a compelling governmental interest.The Supreme Court ruled in favor of the businesses, holding that RFRA applies to regulations that govern the activities of closely held for-profit corporations. The Court declined to “leave merchants with a difficult choice” of giving up the right to seek judicial protection of their religious liberty or forgoing the benefits of operating as corporations. Nothing in RFRA suggests intent to depart from the Dictionary Act definition of “person,” which includes corporations, 1 U.S.C.1; no definition of “person” includes natural persons and nonprofit corporations, but excludes for-profit corporations. “Any suggestion that for-profit corporations are incapable of exercising religion because their purpose is simply to make money flies in the face of modern corporate law.” The Court rejected arguments based on the difficulty of ascertaining the “beliefs” of large, publicly traded corporations and that the mandate itself requires only insurance coverage. If the plaintiff companies refuse to provide contraceptive coverage, they face severe economic consequences; the government failed to show that the contraceptive mandate is the least restrictive means of furthering a compelling interest in guaranteeing cost-free access to the four challenged contraceptive methods. The government could assume the cost of providing the four contraceptives or could extend the accommodation already established for religious nonprofit organizations. The Court noted that its decision concerns only the contraceptive mandate, not all insurance-coverage mandates, e.g., for vaccinations or blood transfusions. View "Burwell v. Hobby Lobby Stores, Inc." on Justia Law

Plaintiffs are non-profit entities affiliated with the Catholic Church who have religious objections to certain preventive care standards under the Patient Protection and Affordable Care Act, 42 U.S.C. 300gg-13, particularly the requirement that their employer-based health insurance plans cover all FDA-approved contraception, sterilization methods, and counseling. All are eligible for either an exemption from the requirement or an accommodation to the requirement, through which the entities will not pay for the contraceptive products and services and the coverage will be independently administered by an insurance issuer or third-party administrator. Nonetheless, they alleged that the contraceptive-coverage requirement violated the Religious Freedom Restoration Act; the Free Speech, Free Exercise, and Establishment Clauses of the First Amendment; and the Administrative Procedure Act. Two district courts denied the appellants’ motions for a preliminary injunction. The Sixth Circuit affirmed, finding that the plaintiffs did not demonstrate a strong likelihood of success on the merits of any of their properly raised claims; because they did not demonstrate a strong likelihood of success on the merits of their claims, they also do not demonstrate that they will suffer irreparable injury without the injunction. View "MI Catholic Conference v. Sebelius" on Justia Law

Plaintiff sought insurance coverage for gastric lap band surgery. Defendant, a health-care insurer that covered Plaintiff by virtue of Plaintiff’s husband’s employment with the federal government, refused to cover the full cost of the surgery. Plaintiff brought tort and breach of contract claims against Defendant in the Puerto Rico Court of First Instance. Defendant removed the action to the federal district court, asserting, inter alia, that the Federal Employees Health Benefits Act of 1959 (FEHBA) completely preempted Plaintiff’s local-law claims, thus conferring original jurisdiction on the federal court. Defendant then moved to dismiss the case, arguing that the FEHBA demanded exhaustion of administrative remedies. Plaintiff, in the meantime, requested that the district court remand the case to the Court of First Instance. The district court (1) denied Plaintiff’s motion to remand, holding that the FEHBA completely preempted Plaintiff’s claims and, thus, federal jurisdiction attached; and (2) dismissed the action for Plaintiff’s failure to exhaust administrative remedies. The First Circuit Court of Appeals reversed the district court’s judgment of dismissal and its order denying remand, holding that the court erred in concluding that the FEHBA afforded complete preemption. View "Lopez-Munoz v. Triple-S Salud, Inc. " on Justia Law

The Providers supply outpatient cardiac telemetry (OCT) services, used by doctors to monitor cardiac arrhythmias. The device differs from conventional technology in that it transmits electrocardiographic (EKG) data in real time to certified technicians, who forward the data to a physician. OCT is approved by the FDA, and has long been covered by Medicare and commercial insurers. CIGNA administers employer sponsored health benefit plans. CIGNA pays its in-network providers directly for the services rendered to patients. In 2007, the Providers joined CIGNA’s network by Agreements that set the reimbursement rate and define “Covered Services.” In 2012, CIGNA issued a statement that it would no longer cover OCT “for any indication because it is considered experimental, investigational or unproven.” The 2012 Policy acknowledged that this new position would be trumped by any conflicting language in the coverage policies themselves. In arriving at the new policy, CIGNA relied on the same medical literature it had previously relied upon in concluding that OCT should be covered. The Providers claim that CIGNA indicated that its motive was financial, but refused to reconsider the 2012 Policy. The district court found that the Providers’ claims fell within the arbitration clause of the Agreement. The Third Circuit vacated. The clause at issue is limited in scope to disputes “regarding the performance or interpretation of the Agreement” and the claims at issue do not relate to the performance or interpretation of the Agreement. View "Cardionet Inc v. Cigna Health Corp." on Justia Law

Lucas County has about 440,000 residents and includes Toledo. Two-thirds of the county’s patients have government-provided health insurance, such as Medicare or Medicaid; 29 percent have private insurance, which pays significantly higher rates to hospitals than government-provided insurance. General acute-care (GAC) inpatient services include “primary services,” such as hernia surgeries, radiology services, and most inpatient obstetrical (OB) services. “Secondary services,” such as hip replacements and bariatric surgery, require more specialized resources. “Tertiary services,” such as brain surgery and treatments for severe burns, require even more specialized resources. “Quaternary services,” such as major organ transplants, require the most specialized resources. Different hospitals offer different levels of service. In Lucas County ProMedica has 46.8% of the GAC market and operates three hospitals, which together provide primary (including OB), secondary, and tertiary services. Mercy Health Partners has 28.7% of the GAC market and operates three hospitals in the county, which provide primary (including OB), secondary, and tertiary services. University of Toledo Medical Center (UTMC) has 13% of the GAC market with a single teaching and research hospital, focused on tertiary and quaternary services. It does not offer OB services. St. Luke’s Hospital had 11.5% of the GAC market and offered primary (including OB) and secondary services. In 2010 ProMedica merged with St. Luke’s, creating an entity with 50% of the market in primary and secondary services and 80% of the market for obstetrical services. The FTC challenged the merger under the Clayton Act, 15 U.S.C. 18. The Commission found that the merger would adversely affect competition and ordered ProMedica to divest St. Luke’s. The Sixth Circuit upheld the order. View "ProMedica Health Sys., Inc. v. Fed. Trade Comm'n" on Justia Law

Plaintiffs worked until 2006, when the plant closed, and retired under a collective bargaining agreement (CBA); that provided that the employer would provide health insurance, either through a self-insured plan or under a group insurance policy and identified the employer’s contribution to the premium. The CBAs provided that the coverage an employee had at the time of retirement or termination at age 65 or older other than a discharge for cause “shall be continued thereafter provided that suitable arrangements for such continuation[] can be made… In the event… benefits … [are] not practicable … the Company in agreement with the Union will provide new benefits and/or coverages as closely related as possible and of equivalent value." In 2011 TRW (the employer’s successor) stated that it would discontinue group health care coverage beginning in 2012, but would be providing “Health Reimbursement Accounts” (HRAs) and would make a one-time contribution of $15,000 for each eligible retiree and eligible spouse in 2012, and in 2013, would provide a $4,800 credit to the HRAs for each eligible party. The HRAs shifted risk, and potentially costs, to plaintiffs. TRW did not commit to funding the HRAs beyond 2013. Plaintiffs sued, claiming that the change breached the CBAs, in violation of the Labor-Management Relations Act, 29 U.S.C. 185, and the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court certified a class and granted summary judgment, ruling that the CBAs established a commitment to lifetime health care benefits. The Sixth Circuit affirmed View "United Steel, Paper, Forestry, Rubber, Mfg. Energy, Allied Indus. & Serv. Workers Int'l Union v. Kelsey-Hayes Co." on Justia Law

The Affordable Care Act, 42 U.S.C. 300gg-13(a)(4), requires health insurance providers (including third party administrators) to cover certain preventive services without cost to the insured, including, “with respect to women … preventive care and screenings,” including all FDA-approved contraceptive methods, sterilization, and patient education for women with reproductive capacity. The University of Notre Dame self‐insures employees’ medical expenses; Meritain administers the employee health plan. For students’ medical needs, Notre Dame has a contract with Aetna. Because Catholic doctrine forbids the use of contraceptives, Notre Dame has never paid for contraceptives for employees or permitted Aetna to insure the expense of contraceptives. Because of those religious objections and the Religious Freedom Restoration Act, 42 U.S.C. 2000bb‐1(a), the government created a religious exemption, 45 C.F.R. 147.130(a)(1)(iv)). New regulations enlarged the exemption, so that Notre Dame came within its scope. To exercise its right to opt out of paying for coverage for contraceptives, the university completed a form that alerts insurers that Notre Dame is not going to pay, so they will have to pay. The government will reimburse at least 110 percent of the third‐party administrator’s costs and Aetna can expect to recoup its costs from savings on pregnancy medical care. Several months after the regulations were promulgated, the University unsuccessfully sought a preliminary injunction. The Seventh Circuit affirmed, noting that the University had not indicated exactly what it wanted enjoined at this stage. The insurance companies were not parties, and, therefore, could not be enjoined from providing the required coverage. A religious institution has no right to prevent other institutions from engaging in acts that merely offend the institution and the University has complied by completing the required form. View "Univ. of Notre Dame v. Sebelius" on Justia Law

A Vermont statute requires all "health insurers" to file with the State reports containing claims data and other "information relating to health care." Liberty Mutual sought a declaration that the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq., preempted the Vermont statute and regulation. The district court granted summary judgment in favor of Vermont. The court held that the reporting requirements of the Vermont statute and regulation have a "connection with" ERISA plans and were therefore preempted as applied. The court's holding was supported by the principle that "reporting" is a core ERISA function shielded from potentially inconsistent and burdensome state regulation. Accordingly, the court reversed and remanded with instructions to enter judgment for Liberty Mutual. View "Liberty Mutual Ins. Co. v. Donegan" on Justia Law

In March 2010, Justyna Kunz was involved in a car accident with GEICO's insureds, Crystal, Joseph, and Elizabeth Kalish. Kunz received medical treatment at Athens Regional Medical Center; the Hospital Authority of Clarke County and Athens Regional Medical Center (collectively, "the Hospitals") filed three hospital liens. Kunz subsequently filed suit against the Kalishes. Kunz's attorney wrote a letter to the Kalishes' attorney accepting their $100,000 policy limit settlement offer. The settlement documents, signed in Fall 2010, expressly required Kunz to satisfy the hospital liens out of the settlement fund and constituted a "general[ ] release ... from all legal and equitable claims of every kind and nature." The liens were never satisfied. The Court of Appeals held that, under OCGA 44–14–473 (a), the Hospitals were barred by a one-year statute of limitations from filing suit against GEICO to collect on the hospital liens. The Hospitals appealed the appellate court's decision. Finding that the appellate court erred in arriving at its conclusion, the Supreme Court reversed. View "Hospital Authority of Clarke County v. GEICO General Insurance Co." on Justia Law