Lynch v. National Prescription Administrators 33 EBC 1199 (S.D. N.Y. 2004).
Claim Denial Dispute
Insurer, as an ASO administrator denied a claim (Sleep Clinic) alleging the bill was padded by unbundling. The provider-assignee demanded details of the insurer’s claims guidelines; request was refused. The court held for the provider-assignee, it did not have to disclose the details of its claims guidelines.
Aetna Life Ins. Co. v. DFW Sleep Diagnostics Center, 33 EBC 1104 (E.D. Ca. 2004).
Employee-Pay-All Dental Plan
Aggrieved participant sued the employer for unpaid claims but employer, while named plan administrator, said the suit should have been against the drug plan. The court said since the employer had its name on the SPD as plan administrator, it was liable regardless of other terms, provisions or arrangements.
Creighton v. Continental Airlines, Inc. 33 EBC 1053 (M.D. Fla. 2004
Where participant and its attorney clearly ignored plan’s subrogation provisions, the court allowed the plan to invoke its subrogation provision as an equitable matter. In the division of insurance company’s settlement proceeds, the attorney was permitted to collect its fees under the so-called common fund principles.
Mank v. Green, 33 EBC 1055 (D. Me. 2004).
HMO Wrongful Claim Denial
An injunction was delivered by the court requiring the HMO to cover what the HMO argued was an experimental procedure. The court ruled that the good to the participant exceeded the harm to the HMO.
Chambers v. Coventry Health Care of Louisiana 33 EBC 1074 (E.D. La. 2004).
The participant argued that Knudson v. Great-West made subrogation a state and not a federal issue. The court held otherwise.
MEBA Medical & Benefits Plan v. Logo 33 EBC 1118 (Fla. Ct. App. 2004).
TPA-Not a Fiduciary
© 2004 International Foundation of Employee Benefit Plans, Inc. All rights reserved.