Justia Insurance Law Opinion Summaries

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

Plaintiff, 37-years-old, suffered from anorexia nervosa for more than twenty years. At issue was whether defendant was required to pay for her care at a residential treatment facility, either under the terms of her insurance plan or under California's Mental Health Parity Act (Parity Act), Cal. Health & Safety Code 1374.72. The court held that plaintiff's plan did not itself require that defendant pay for residential care for her anorexia nervosa. The court held, however, that the Parity Act provided that defendant "shall provide coverage for the diagnosis and medically necessary treatment" of "severe mental illnesses," including anorexia nervosa. Therefore, defendant was foreclosed from asserting that plaintiff's residential care was not medically necessary. Accordingly, the court held that defendant was obligated under the Parity Act to pay for plaintiff's residential care, subject to the same financial terms and conditions it imposed on coverage for physical illnesses.

After self-insured Employer filed for bankruptcy, it continued to take payroll deductions from Employees for medical coverage but stopped paying the provider hospital for the covered charges. The hospital then directly billed Employees for services that should have been paid by Employer. Employees filed suit to stop the hospital's attempts to collect payment, seeking relief under the theories of declaratory judgment, injunction, breach of contract, negligent infliction of emotional distress, and bad faith breach of contract. The circuit court granted summary judgment in favor of the hospital on all of Employees' claims. The Supreme Court reversed, holding (1) Employees had standing as third party beneficiaries to enforce the provisions of the hospital agreement and payer agreement; and (2) Employees were not obligated to pay for covered medical services under the agreements. Remanded.

Plaintiffs, a class of economically vulnerable Arizonians who receive public health care benefits through the state's Medicaid agency, sued the U.S. Secretary of Health and Human Services (Secretary) and the Director of Arizona's medicaid agency (director)(collectively, defendants), alleging that the heightened mandatory co-payments violated Medicaid Act, 42 U.S.C. 1396a, cost sharing restrictions, that the waiver exceeded the Secretary's authority, and that the notices they received about the change in their health coverage was statutorily and constitutionally inadequate. The court affirmed the district court's conclusion that Medicaid cost sharing restrictions did not apply to plaintiffs and that Arizona's cost sharing did not violate the human participants statute. The court reversed the district court insofar as it determined that the Secretary's approval of Arizona's cost sharing satisfied the requirements of 42 U.S.C. 1315. The court remanded this claim with directions to vacate the Secretary's decision and remanded to the Secretary for further consideration. Finally, the court remanded plaintiffs' notice claims for further consideration in light of intervening events.

This case arose when plaintiff was seriously injured in an automobile accident negligently caused by a driver for defendant. At issue was whether an injured person could recover from the tortfeasor, as economic damages for past medical expenses, the undiscounted sum stated in the medical care provider's bill but never paid by or on behalf of the injured person. The court held that the collateral source rule, which precluded deduction of compensation the plaintiff had received from sources independent of the tortfeasor from damages the plaintiff "would otherwise collect from the tortfeasor" ensured that plaintiff here could recover in damages the amounts her insurer paid for her medical care. The rule, however, had no bearing on amounts that were included in a provider's bill but for which the plaintiff never incurred liability because the provider, by prior agreement, accepted a lesser amount as full payment. Such sums were not damages the plaintiff would otherwise have collected from the defendant and were neither paid to the providers on the plaintiff's behalf nor paid to the plaintiff in indemnity of his or her expenses. Therefore, because they did not represent an economic loss for the plaintiff, they were not recoverable in the first instance. The collateral source rule precluded certain deductions against otherwise recoverable damages, but did not expand the scope of economic damages to include expenses the plaintiff never incurred.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660â61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

After suffering a work-related injury, Employee underwent surgery at a hospital owned by HealthEast Care System. The injury required surgical implantation of a spinal cord stimulator. Employer's worker's compensation insurance provider, State Auto Insurance, paid part but not all of the surgical expenses, asserting (1) the withheld portion of the expenses was attributable to a price markup added by HealthEast to the price paid by HealthEast for the implant hardware used in Employee's surgery, and (2) the manufacturer of the implant hardware should be required to charge directly for the implant hardware. The compensation judge found that Employer and State Auto were liable for the unpaid balance. The Workers' Compensation Court of Appeals affirmed. The Supreme Court affirmed, holding (1) HealthEast could charge for the implant hardware because when more than one health care provider is responsible for the creation of a service, article, or supply, the provider that provides the service, article, or supply in its final form is entitled to charge for it; and (2) a compensation judge does not have the authority to determine a reasonable value of a treatment, service, or supply that is lower than eighty-five percent of the provider's usual or customary charge.

When plaintiffs left their jobs, they did not receive notices describing how to extend their health insurance coverage within the period prescribed by statute (COBRA notices). Responding to solicitation from a lawyer, they became named plaintiffs in a proposed class action seeking damages from and statutory penalties against their former employer. The district court declined to certify the class and, on consideration of the individual claims, denied the request for statutory penalties and one of the plaintiffs' requests for damages. The Seventh Circuit affirmed. The district court properly denied class certification because it found the proposed class counsel inadequate to represent the class, based on observations about counsel's diligence, respect for judicial resources, and promptness. Denial of statutory penalties under 29 U.S.C. 1132 was appropriate; there was no evidence of an administrator's bad faith (such as misrepresentations or willful delay in response to requests for information) or gross negligence. The district court was within its discretion in denying damages as compensation for expenses, where there was no evidence to indicate that the expenses were incurred as a result of the failure to provide timely notice of COBRA rights.

Doctors and a patient challenged the Patient Protection and Affordable Care Act requirement, effective in 2014, that all non-exempt applicable individuals either maintain a certain minimum level of health insurance or pay a monetary penalty (26 U.S.C. 5000A) and a provision that penalizes certain employers if they fail to offer full-time employees the opportunity to enroll in an employer-sponsored insurance plan that satisfies the individual mandate's minimum essential coverage requirement (26 U.S.C. 4980H(a)).The district court dismissed for lack of standing. The Third Circuit affirmed. There is no evidence that the patient-plaintiff or doctors are in any way currently impacted by the law or that harm is imminent.

Plaintiff filed suit against Liberty Mutual, both personally and on behalf of a putative class of similarly situated individuals, alleging that the company's failure to disburse "medical payments" coverage (MedPay) benefits to her constituted a breach of contract, a breach of implied covenant of good faith and fair dealing, and a violation of G.L.c. 93A, 2. At issue was whether a claimant could seek medical expense benefits under the MedPay of a standard Massachusetts automobile insurance policy where she had already recovered for those expenses under a separate policy of health insurance. The court held that plaintiff's complaint and the extrinsic materials submitted by Liberty Mutual contained alleged facts sufficient to "raise a right to relief above the speculative level." The court also held that Liberty Mutual had not demonstrated as a matter of law that plaintiff could not receive MedPay benefits when she already had received medical expense benefits under her policy of health insurance. Accordingly, the order allowing Liberty Mutual's motion to dismiss was reversed and the matter remanded.