On June 5, 2019, in the matter Kerry W. v. Anthem Blue Cross and Shield, No. 2:19cv67, Judge Dee Benson of the U.S. District Court for the District of Utah granted Anthem Blue Cross and Shield’s motion to dismiss the plaintiffs’ cause of action for violation of the Mental Health Parity and Addiction Equality Act (MHPAEA). The district court in Utah continues to determine that a denial of a mental health benefit claim based on medical necessity cannot be transformed into a cause of action for violation of the MHPAEA through conclusory allegations.
In Josef K. v. California Physicians’ Service, No. 18-cv-06385-YGR (U.S. District Court for the Northern District of California, June 3, 2019), Judge Yvonne Gonzalez Rogers concluded that an independent medical review (IMR) organization can be subject to a claim under the Employee Retirement Income Security Act of 1974 (ERISA) as amended, 29 U.S.C. 1132(a)(3), for breach of fiduciary duties based on the review of a medical necessity appeal under an ERISA-governed employee welfare benefit plan.
Behavioral health claims administrators and plan sponsors alike may be looking more closely at their care guidelines—and how they are applied—after a federal court ruled in a California class action that a claims administrator had breached its fiduciary duty under the Employee Retirement Income Security Act of 1974 (ERISA) by applying standards of care that were more restrictive than generally accepted standards and by improperly prioritizing cost savings.
When applying de novo review to a claim for disability benefits under a group disability policy governed by the Employee Retirement Income Security Act of 1974 (ERISA), district courts must consider all the evidence and determine if a preponderance of that evidence establishes entitlement to benefits.
Litigation under the Employee Retirement Income Security Act (ERISA) involving the payment of benefits for residential treatment can be challenging—particularly when those claims involve eating disorders. A patient may argue that if treatment is discontinued prematurely, he or she will decompensate, lose the benefit of prior treatment, and risk physical and emotional harm.
In 2011, the California legislature passed Insurance Code Section 10110.6 which bans the use of discretionary clauses in any policy, contract, certificate, or agreement offered, issued, delivered, or renewed, whether or not in California, that provides or funds life insurance or disability insurance coverage. The district courts in California have enthusiastically enforced this ban, holding that discretionary clauses are unenforceable in group insurance policies and self-funded employee welfare benefit plans that provide disability benefits.
Courts often do not clearly articulate what are key arguments in defending an action under the Employee Retirement Income Security Act of 1974 (ERISA) involving a claim for benefits based on subjective complaints. However, the stars recently aligned and U.S. District Judge Michael W. Fitzgerald of the Central District of California did just that in Haber v. Reliance Standard Life Insurance Company, No. 14-9566, 2016 WL 4154917 (August 4, 2016). He concluded that the plaintiff Orly Haber did not prove that her upper extremity pain complaints were severe enough to preclude her from performing an occupation normally performed in the national economy for which she was reasonably suited based upon her education, training, or experience (the “any occupation” standard).
Last week, the Ninth Circuit Court of Appeals issued its opinion in LeGras v. AETNA Life Insurance Company, No. 12-56541 (May 28, 2015), holding that the 180-day period to appeal a denial of a long-term disability claim was extended to the following Monday because the last day to submit the appeal fell on a Saturday.