By: Michael Stevens and Ronald Kramer
Seyfarth Synopsis: The Sixth Circuit becomes the seventh circuit court to not require administrative exhaustion for statutory ERISA claims (as opposed to denial of benefit claims), while two circuit courts still do.
In a decision earlier this month, the Sixth Circuit joined six other circuit courts in holding that…
By: Alexius O’Malley and Sam Schwartz-Fenwick
Seyfarth Synopsis: A Court ruled that under the Affordable Care Act, an ERISA governed plan exclusion cannot unequivocally bar emergency medical care related to injuries sustained in a fireworks explosion.
Recently, a federal court in Minnesota addressed whether a participant in a self-funded ERISA-governed welfare plan, could recover $225,000…
By: Amanda Sonneborn and Thomas Horan
Be careful what you ask for. The Plaintiff in a recent case from the Central District of California learned that lesson when the Plan’s re-evaluation of her claim for benefits revealed that she was apparently working as a stunt coordinator and stunt actress, despite having received disability pension payments…
By: Amanda Sonneborn and Jules Levenson
Seyfarth Synopsis: Court excludes evidence of Social Security disability award issued after the final decision issued on plaintiff’s claim for plan disability benefits. The decision accentuates the importance of fighting to limit the evidence before a Court on review of a plan administrator’s decision.
Just like football is a…
By: Jules Levenson, Meg Troy and Ian H. Morrison
Knowingly spending money that isn’t yours sounds like a no-no, but depending on how the Supreme Court rules in Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan (No. 14-723), certain ERISA plan participants may well have that perverse incentive, owing…
By Ward Kallstrom and Andrew Scroggins
Claims by providers seeking to assert the rights of ERISA plan participants have been percolating in courts throughout the country.[1] The Seventh Circuit has now weighed in, rejecting the notion that providers who have payment disputes with ERISA plans are entitled to utilize a plan’s ERISA-mandated claims appeal…
By: Amanda Sonneborn and Christopher Busey
In Mirza v. Insurance Administrator of America, Inc., No. 13-3535 (3d Cir. August 26, 2015), the Third Circuit became the latest Court to require benefit denial letters to include a notification of the plan’s limitations period for bringing suit. In reaching this conclusion, it joined the First and…
By: Jon Braunstein and Nabeel Ahmad
In a recent decision, the Ninth Circuit Court of Appeals rejected a Plan participant’s attempt to extend California insurance law’s notice-prejudice rule to self-insured ERISA plans. Zagon v. Am. Airlines, Inc., 2015 BL 160778, 9th Cir., No. 13-55866 (5/21/15) (unpublished).
The pertinent case facts are these: Zagon, a…
By: Sam Schwartz-Fenwick and Amanda Sonneborn
In last week’s oral argument on the constitutionality of same-sex marriage bans, Chief Justice Roberts asked the following question:
Counsel, I’m I’m not sure it’s necessary to get into sexual orientation to resolve the case. I mean, if Sue loves Joe and Tom loves Joe, Sue can marry…
By: Amanda Sonneborn and Meg Troy
The Fifth Circuit recently addressed an out-of-network provider’s right to sue and whether coverage may be conditioned on collections of patient’s out of pocket costs. North Cypress Medical Ctr. Operating Co., et al. v. Cigna Healthcare, et al., No. 12-20695.
North Cypress owns and operates a hospital in…
