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Hall Benefits Law

Court Orders Claims Reprocessing After Finding TPA Illegally Excluded Gender-Affirming Care in Violation of ACA Section 1557

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A federal district court has awarded injunctive relief, including claims processing, after finding that an insurer acting as a third-party administrator (TPA) for a self-insured plan violated Section 1557 of the Affordable...more

Jackson Walker

Summary of HB 3359: Changes to Preferred Provider Benefit Plans

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HB 3359 amends Chapter 1301 of the Texas Insurance Code. Chapter 1301 sets forth the legal requirements and obligations of a “preferred provider benefit plan”. A “preferred provider benefit plan” is a benefit plan in which an...more

Faegre Drinker Biddle & Reath LLP

Louisiana Secures Temporary Injunction in Connection with the SHIP Rehabilitation Plan

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Senior Health Insurance Company of Pennsylvania (“SHIP”) was placed in rehabilitation in Pennsylvania in January 2020. On August 24, 2021, the Commonwealth Court of Pennsylvania approved the Rehabilitation Plan (the “Plan”),...more

Wiley Rein LLP

Insured Barred From Settling Without Insurer’s Consent Absent Breach of Duty to Defend But Insurer Must Exercise Good Faith in...

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The United States District Court for the District of South Dakota, applying South Dakota law, has held that an insured healthcare system was barred from settling without its healthcare liability insurer’s consent where the...more

K&L Gates LLP

Recent District Court Decision Highlights the Importance of Adequate Behavioral Health Claims Processing Guidelines for ERISA...

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On this week’s episode, Carla DewBerry and Sarah Carlins discuss a recent California Federal District Court decision in David Wit v. United Behavioral Health, in which the court found that the defendant insurer violated ERISA...more

Haight Brown & Bonesteel LLP

Unreasonableness of Insurer’s “Medical Necessity” Criteria and Inconsistent Expert Testimony Mandate Reversal of Genuine Dispute...

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In Ghazarian v. Magellan Health (No. G057113, filed 8/7/20), a California appeals court reversed summary judgment that had been granted for a health plan insurer in a bad faith and unfair business practices lawsuit on the...more

Carlton Fields

Seventh Circuit Rejects Third-Party Administrator’s Attempt to Avoid Multimillion-Dollar Arbitration Award

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Standard Security Life Insurance Company of New York and Madison National Life Insurance Co. entered into an administrative services agreement with FCE Benefit Administrators Inc. under which FCE administered insurance...more

Holland & Knight LLP

Health Insurers Take Hit From Appeals Court Ruling on ACA's Risk Corridor Program

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• Health insurers seeking payment under the Affordable Care Act's Risk Corridor Program were dealt a blow following a recent U.S. Court of Appeals for the Federal Circuit ruling that reversed an earlier decision against the...more

Haight Brown & Bonesteel LLP

Insured Plaintiff Who Treats Outside Medical Plan on Lien Basis is Deemed Uninsured Under the Law Allowing Potential Recovery for...

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This week, the California Court of Appeal, Second Appellate District, Division Six held in Pebley v. Santa Clara Organics, LLC et al., (No. B277893) that an insured plaintiff who elects to treat out-of-network shall be...more

Butler Snow LLP

Bills, Bills, Bills: Calculation of Past Medical Expenses under Texas Law

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Under Texas law, recovery of past medical expenses is limited to the amount actually paid or incurred. Section 41.0105 was enacted in 2003 by the Texas Legislature as a tort reform initiative to limit past medical damages to...more

Carlton Fields

Eighth Circuit Upholds Dismissal Of Claim Against Department Of Health & Human Services Under ACA Transitional Reinsurance Program...

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Seeking reimbursement of fees paid, allegedly by mistake, under the transitional reinsurance program in the Patient Protection and Affordable Care Act (“ACA”), the trustees of the Twin City Pipe Trades Welfare Fund’s sued the...more

Carlton Fields

Recent Ninth Circuit Rulings Uphold Plaintiffs’ Efforts to Predicate Claims on Alleged Insurance Code Violations — Likely More to...

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Recent rulings suggest insurers face increased risk of suits predicating breach of contract and state unfair trade practices claims on alleged violation of state insurance laws, notwithstanding the lack of an express private...more

Butler Weihmuller Katz Craig LLP

Florida's SIU Tool Belt Is a Bit Lighter Today

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Florida has been plagued with insurance fraud for decades.  All insurance coverages are susceptible to fraud, but scams are especially prevalent in the context of automobile accidents.  Staged crashes, patient brokering,...more

Faegre Drinker Biddle & Reath LLP

Third Cir. Holds Hospitals May Sue Health Insurers Directly

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Before September 11 the Third Circuit Court of Appeals had been out of step with its sister federal circuits when it came to the right of hospitals, physicians and other health providers to sue health insurers that failed to...more

Faegre Drinker Biddle & Reath LLP

Insurer’s Agreements with Providers Are Not Per Se Antitrust Violations

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The Iowa Supreme Court refused to categorize a health insurer’s agreements with providers in Iowa and its participation in the national Blue Cross and Blue Shield (BCBS) network as per se violations of the antitrust laws. ...more

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