Justia Insurance Law Opinion Summaries

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

After discovering that she had lung cancer that had spread to her brain, Killian underwent aggressive treatment on the advice of her doctor. The treatment was unsuccessful and she died. Her husband submitted medical bills for the cost of the treatments to her health insurance company. The company denied coverage on most of the expenses because the provider was not covered by the insurance plan network. The husband filed suit, seeking benefits for incurred medical expenses, relief for breach of fiduciary duty, and statutory damages for failure to produce plan documents. The district court dismissed denial-of-benefits and breach-of-fiduciary-duty claims, but awarded minimal statutory damages against the plan administrator. In 2012, the Seventh Circuit affirmed the dismissals, rejecting an argument that the plan documents were in conflict, but remanded for recalculation of the statutory damages award. On rehearing, en banc, the Seventh Circuit affirmed the denial of benefits and statutory penalties holdings, but reversed on the breach of fiduciary duty claim. The instructions given in plan documents were deficient and a reasonable trier of fact could rule in favor of Killian, based on telephone conversations in which Killian attempt to determine whether the physicians who were about to perform surgery were within the network. View "Killian v. Concert Health Plan" on Justia Law

Kennedy family members own a controlling interest in corporate entities that comprise Autocam. John Kennedy is Autocam’s CEO. The companies are for-profit manufacturers in the automotive and medical industries and have 661 employees in the U.S. The Kennedys are practicing Roman Catholics and profess to “believe that they are called to live out the teachings of Christ in their daily activity and witness to the truth of the Gospel,” which includes their business dealings. Regulations under the Patient Protection and Affordable Care Act of 2010 (ACA), 124 Stat. 119, require that Autocam’s health care plan cover, without cost-sharing, all FDA-approved contraceptive methods, sterilization, and patient education and counseling for enrolled female employees. Autocam and the Kennedys claim that compliance with the mandate will force them to violate their religious beliefs, in violation of the Religious Freedom Restoration Act, 42 U.S.C. 2000bb. The district court denied their motion for a preliminary injunction. The Sixth Circuit affirmed for lack of standing. Recognition of rights for corporations under the Free Speech Clause 20 years after RFRA’s enactment does not require the conclusion that Autocam is a “person” that can exercise religion for purposes of RFRA. View "Autocam Corp. v. Sebelius" on Justia Law

Plaintiffs, insured under employer health plans, filed a proposed class action alleging that health-insurance companies violated Wisconsin law by requiring copayments for chiropractic care. The insurance code prohibits insurers from excluding coverage for chiropractic services if their policies cover the diagnosis and treatment of the same condition by a physician or osteopath. The policies at issue provide chiropractic coverage, although, like other services, it is subject to copayment requirements. The complaint cited provisions of the Employee Retirement Income Security Act for recovery of benefits due, 29 U.S.C. 1132(a)(1)(B) & 502(a)(3), and for breach of fiduciary duty, sections 1132(a)(3), 1104. The district court dismissed. The Seventh Circuit affirmed. Nothing in ERISA categorically precludes a benefits claim against an insurance company. The complaint alleges that the insurers decide all claims questions and owe the benefits; on these allegations the insurers are proper defendants on the 1132(a)(1)(B) claim. The complaint nonetheless fails to state a claim for breach of fiduciary duty; setting policy terms, including copayments, determines the content of the policy, and decisions about the content of a plan are not themselves fiduciary acts. View "Larson v. United Healthcare Ins. Co." on Justia Law

The Fund is a multi-employer trust fund under the Taft-Hartley Act, 29 U.S.C. 186, and the Employee Retirement Income Security Act, 29 U.S.C. 1001. Blue Cross is a Michigan non-profit corporation; its enabling statute authorizes the State Insurance Commissioner to require it to pay a cost transfer of one percent of its “earned subscription income” to the state for use to pay costs beyond what Medicare covers. In 2002 the Fund converted to a self-funded plan, and entered into an Administrative Services Contract with Blue Cross, which states that Blue Cross is not the Plan Administrator, Plan Sponsor, or fiduciary under ERISA; its obligations are limited to processing and paying claims. In 2004 the Fund sued, claiming that Blue Cross breached ERISA fiduciary duties by imposing and failing to disclose a cost transfer subsidy fee to subsidize coverage for non-group clients. The fee was regularly collected from group clients. Self-insured clients were not always required to pay it. Following a first remand, the district court granted class certification and granted the Fund summary judgment. On a second remand, the court again granted judgment on the fee imposition claim and awarded damages of $284,970.84 plus $106,960.78 in prejudgment interest. The Sixth Circuit affirmed. View "Pipefitters Local 636 Ins. Fund v. Blue Cross & Blue Shield of MI" on Justia Law

Appellant received treatment at Hospital for injuries she sustained in an automobile accident. Appellant granted two statutory liens to Hospital on settlement proceeds she obtained from the tortfeasor for hospital services rendered. Appellant subsequently settled her case against the tortfeasor, and the tortfeasor's insurer (Insurer) agreed to pay Appellant $1.3 million in exchange for Appellant's agreement to indemnify Insurer from all healthcare provider liens. Hospital subsequently sued Insurer, and Appellant tendered to Hospital all money it asserted was due. Appellant then filed a complaint against Hospital, alleging that Hospital overcharged her pursuant to Nev. Rev. Stat. 439B.260(1), which provides that hospitals must reduce charges by thirty percent to inpatients who lack insurance "or other contractual provision for the payment of the charge by a third party." The district court entered judgment in favor of Hospital, finding that Appellant's settlement agreement with the tortfeasor rendered Appellant ineligible for the thirty percent statutory discount. The Supreme Court reversed in part, holding that a patient's eligibility is determined at the commencement of hospital services, and therefore, a later settlement agreement with a third party for the payment of such services does not disqualify the patient for the statutory discount. View " Bielar v. Washoe Health Sys., Inc." on Justia Law