Justia Insurance Law Opinion Summaries

Plaintiff appealed the district court's summary judgment dismissing her suit to recover health insurance benefits under an employee plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001-1461. Aetna, a Texas health maintenance organization (HMO), provided and administered the plan's health insurance benefits under an agreement giving Aetna discretion to interpret the plan's terms. Aetna refused to reimburse plaintiff for care she received from a specialist outside of the Aetna HMO to whom she had been referred by a physician in the HMO. Aetna denied her claim because the referral was not pre-authorized by Aetna. The district court found as a matter of law that Aetna did not abuse its discretion in denying coverage. The court found, however, that the plan was ambiguous and the need for pre-authorization was not clearly stated in Aetna's summary description of the plan. And under the circumstances of the case, it could not be said as a matter of law that Aetna did not abuse its discretion in denying coverage.

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 months later. 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. 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.

Plaintiff, a maintenance director, had a stroke and began leave under the Family and Medical Leave Act, 29 U.S.C. 612(a)(1) in January 2008. He received disability benefits from Unum. The doctor cleared him to return to work starting on May 1, with conditions that he not work more than four hours per day or lift loads in excess of 20 pounds. The administrator notified plaintiff that part-time work was not available. The doctor cleared him to work full-time, but did not change the lifting restriction. On April 20, the employer terminated plaintiff's employment and notified him that he would not be rehired with lifting restrictions. Until July 2008, when the restrictions were lifted, he received benefits from Unum. The district court rejected claims under the Americans with Disabilities Act, the Pennsylvania Human Relations Act, and the FMLA. The Third Circuit affirmed. The FMLA does not require an employer to provide reasonable accommodation to facilitate return to an equivalent position following leave. Entitlement to restoration requires that the employee be able to perform essential job functions without accommodation. Having represented to Unum that he was disabled, plaintiff was estopped from claiming that he was able to perform all essential functions.

Plaintiff represented psychiatrists who treated patients eligible for both Medicare and Medicaid and defendants were responsible for administering Medicaid in New York and for implementing and enforcing medicaid reimbursement rates. At issue was whether the 2006 amendment to the Social Services law found in a budget bill implementing a coinsurance enhancement for the benefit of psychiatrists who treat patients eligible for both Medicare and Medicaid was intended to be permanent or whether the amendment was intended only to provide a limited one-year enhancement. The court concluded that the Legislature only intended to provide for a one-time coinsurance enhancement, limited to the 2006-2007 fiscal year.

Insurers sought a declaration that they had no duty to defend or indemnify in tort suits brought against the insured village, concerning discovery of "perc," a carcinogenic common dry cleaning solvent, in one of its wells and the village's continued use of the well without disclosure. The district court, relying on a pollution exclusion in the policies, granted summary judgment for the insurers. The exclusion refers to "actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of 'pollutants'" and excludes from coverage expenses for "cleaning up ... or in any way responding to, or assessing the effects of pollutants." After exploring the reasons for the exclusion, the Seventh Circuit affirmed. The court rejected an argument that this was not a pollution case, because the amount of perc in the water was below the maximum level permitted by environmental regulations. The complaints actually filed "describe in copious detail the conduct giving rise to the tort suits, and in doing so inadvertently but unmistakably acknowledge the applicability of the pollution exclusion."

The Department of Public Welfare (DPW) and the Office of the Budget of the Commonwealth of Pennsylvania appealed a Commonwealth Court order which granted summary judgment to Appellees the Pennsylvania Medical Society and its individual members, and the Hospital and Healthsystem Association of Pennsylvania and its individual members. The court declared that the Commonwealth had an obligation under the Health Care Provider Retention Law (the Abatement Law) to transfer monies to the Medical Care Availability and Reduction of Error Fund (MCARE Fund) in an amount necessary to fund dollar for dollar, all abatements of annual assessments granted to health care providers for the years 2003-2007. Upon review of the Commonwealth Court record, the Supreme Court held that the Abatement Law gave the Secretary of the Budget the discretion, but not the obligation, to transfer monies into the MCARE Fund in an amount up to the total amount of abatements granted. Furthermore, the Court concluded that Apellees had no statutory entitlement to the funds held in abatement, nor a vested right to them.

The issue in this case was whether a healthcare provider could be held liable for damages when the provider's negligence permitted the theft of its patients' personal information, though the information was never used or viewed by the thief or any other person. Plaintiffs Laurie Paul and Russell Gibson (individually and on behalf of all similarly-situated individuals) claimed economic and noneconomic damages for financial injury and emotional distress that they allegedly suffered when, through Defendant Providence Health System-Oregon's alleged negligence, computer disks and tapes containing personal information from an estimated 365,000 patients (including Plaintiffs') were stolen from the car of one of Defendant’s employees. The trial court and Court of Appeals held that Plaintiffs had failed to state claims for negligence or for violation of the Unlawful Trade Practices Act (UTPA). Upon review, the Supreme Court concluded that, in the absence of allegations that the stolen information was used in any way or even was viewed by a third party, Plaintiffs did not suffer an injury that would provide a basis for a negligence claim or an action under the UTPA.

Main & Associates, Inc., d/b/a Southern Springs Healthcare Facility, filed an action in the Bullock Circuit Court, on behalf of itself and a putative class of Alabama nursing homes, against Blue Cross and Blue Shield of Alabama (BCBS), asserting claims of breach of contract, intentional interference with business relations, negligence and/or wantonness, and unjust enrichment and seeking injunctive relief. BCBS removed the case to the the federal court, arguing among other things, that Southern Springs' claims arose under the Medicare Act and that the Medicare Act, as amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (the MMA) completely preempted Southern Springs' state-law claims. Southern Springs moved the federal court to remand the case to the circuit court, arguing that the federal court did not have jurisdiction over its claims. The federal court granted the motion and remanded the case to the Bullock Circuit Court. After remand, BCBS moved the circuit court for a judgment on the pleadings, arguing that Southern Springs had not exhausted its administrative remedies and that the circuit court did not have subject-matter jurisdiction over the case. The circuit court denied BCBS's motion, and BCBS petitioned the Supreme Court for a writ of mandamus to direct the circuit court to dismiss Southern Springs' claims. Upon review, the Court concluded that Southern Springs' claims were inextricably intertwined with claims for coverage and benefits under the Medicare Act and that they were subject to the Act's mandatory administrative procedures and limited judicial review. Southern Springs did not exhaust its administrative remedies, and the circuit court did not have jurisdiction over its claims. Therefore, the Court granted BCBS's petition and issue a writ of mandamus directing the circuit court to dismiss the claims against BCBS.

Alohacare, a health maintenance organization (HMO), submitted a proposal to the Department of Human Services to bid for a Quest Expanded Access contract to provide healthcare services for participants in the state's Medicaid program. The Department of Human Services awarded Quest contracts to United HealthCare Insurance (United) and WellCare Health Insurance (Ohana) but not to Alohacare. Alohacare petitioned the Insurance Commissioner of the Department of Commerce and Consumer Affairs for declaratory relief that the Quest contracts required the accident and health insurers to carry an HMO license. The Commissioner concluded that the license was not required to offer the Quest managed care product because the services required under the contracts were not services that could be provided only by an HMO. The circuit court affirmed. The Supreme Court affirmed, holding (1) AlohaCare had standing to appeal the Commissioner's decision; (2) both accident and health insurers and HMOs were authorized to offer the model of care required by the Quest contracts; and (3) this holding did not nullify the Health Maintenance Organization Act.

Appellant filed a declaratory judgment action seeking a declaration that AHCCCS had no right to recover from her father's annuity at all or, alternatively, had no right to recover for any costs incurred for the care of her mother received after her father's death. Appellant subsequently appealed the district court's judgment granting summary judgment to AHCCCS. The court held that the 2006 amendment to 42 U.S.C. 1396p(c)(1)(F)(i) created a right in the State to recover as a remainder beneficiary against a community spouses' annuity for an institutionalized spouse's medical costs. The court further held that the State's recovery was not limited to the amount it paid for the institutionalized spouse's medical costs as of the date of the community spouse's death. Accordingly, the court affirmed the judgment, concluding that AHCCCS could be reimbursed as the primary remainder beneficiary from the father's annuity for the cost of the medical assistance it paid on the mother's behalf after the father's death.