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ERISA Shield Explosion?

Dx from U.S. Supreme Court?

 

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

PEGRAM et al. v. HERDRICH
U.S. Supreme Court,

Decided 06/12/2000

Healthcare Quality by State Laws or ERISA?

RUSH PRUDENTIAL HMO, INC. v. MORAN

U.S. Supreme Court,

Decided June 20, 2002

Medical Necessity by State Laws or ERISA?

Kentucky Assn. of Health Plans, Inc. v. Miller

U. S. Supreme Court,

Decided: April 2, 2003

Managed Care Networks by State Laws or ERISA?

AETNA HEALTH INC. v. DAVILA

Decided June 21, 2004

Health Care Quality & Cost Control by State Laws or ERISA?

ERISA Shield Explosion!!!

ERISA Patient's Bill of Right from Supreme Court

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

04/28/2004

More details below

06/21/04 02-1845 Aetna Health Inc. v. Davila

Breaking News:

 

Supreme Court Ruling today will change entire health care system. This ruling was correctly predicted by the publisher and editor of ERISAclaim.com, Dr. Jin Zhou, on 04/28/2004.

 

 

 

SUPREME COURT OF THE UNITED STATES
Syllabus
KENNEDY, EXECUTRIX OF THE ESTATE OF KENNEDY,
DECEASED v. PLAN ADMINISTRATOR FOR DUPONT
SAVINGS AND INVESTMENT PLAN ET AL.


CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR
THE FIFTH CIRCUIT
No. 07–636. Argued October 7, 2008—Decided January 26, 2009

 

""2. Although Liv’s waiver was not nullified by §1056’s express terms, the plan administrator did its ERISA duty by paying the SIP benefits to Liv in conformity with the plan documents. ERISA pro-vides no exception to the plan administrator’s duty to act in accor-dance with plan documents. Thus, the Estate’s claim stands or falls by “the terms of the plan,” 29 U. S. C. §1132(a)(1)(B), a straight for-ward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing ofclaims and disbursement of benefits,’ ” Egelhoff v. Egelhoff, 532 U. S. 141, 148. By giving a plan participant a clear set of instructions for making his own instructions clear, ERISA forecloses any justification for enquiries into expressions of intent, in favor of the virtues of adhering to an uncomplicated rule. Less certain rules could force plan administrators to examine numerous external documents purporting to be waivers and draw them into litigation like this over those waivers’ meaning and enforceability......."

ERISAclaim.com Comments (02/4/2009)

 

    In this case, a unanimous U.S. Supreme court ruled that ERISA plan administrator must follow ERISA and Plan documents with no exceptions to decide whom and how much benefits to pay, disregard of state laws and other private non-ERISA agreements.

 

    Although the case background was based on a divorce dispute, the ERISA law is good for healthcare claims as well, 100% same for all claims under ERISA. This unanimous U.S. Supreme court ruling clarifies that ERISA plan must make payments to healthcare providers and accept appeals from healthcare providers if properly authorized under ERISA disregard of any state laws, Insurance Co. or TPA Policies  or managed care  PPO/HMO contracts.

 

This 2009 U.S. Supreme court unanimous answered our current questions if ERISA pre-empts and invalidates all PPO's and state laws!

This is the latest 2009 U.S. Supreme Court unanimous ruling on ERISA, and plan administration, with respect to ERISA, SPD and Sate laws or PPO's (divorce agreement), that ERISA plan administrator need only look at ERISA, SPD and ERISA plan documents, such as patient designation of authorized representive under ERISA, to make benefits decisions, and need to care less about what other private agreement, PPO or divorce agreement, or state laws, divorce decrees in this case, because that is what Congress intended in ERISA laws since 1974, or if that is not fair or right to certain people, they can fight out of my house (ERISA Plan) and sort out their problems in state court.

This is the latest, highest and unanimous ruling from U.S. Supreme court.

The main stream is only look at this case under and within divorce picture, but the ERISA legal principle from this case is for both pension and welfare - healthcare claims.
 

This ERISA assignment rule is also explained in DOL ERISA FAQ B3:

 

"B-3: When a claimant has properly authorized a representative to act on his or her behalf, is the plan required to provide benefit determinations and other notifications to the authorized representative, the claimant, or both?

 

Nothing in the regulation precludes a plan from communicating with both the claimant and the claimant’s authorized representative. However, it is the view of the department that, for purposes of the claims procedure rules, when a claimant clearly designates an authorized representative to act and receive notices on his or her behalf with respect to a claim, the plan should, in the absence of a contrary direction from the claimant, direct all information and notifications to which the claimant is otherwise entitled to the representative authorized to act on the claimant’s behalf with respect to that aspect of the claim (e.g., initial determination, request for documents, appeal, etc.). In this regard, it is important that both claimants and plans understand and make clear the extent to which an authorized representative will be acting on behalf of the claimant."

 

 

 

McDonald, James v. Household Int'l

Seventh Circuit Court of Appeals

09/29/2005

 

Opinion

Oral Argument

Oral Argument

 

"‘make-whole’ relief"?

 

"It will be up to the McDonalds on remand to decide whether they wish to proceed with their case or to abandon it. In that connection, they may wish to take note of Justice Ginsburg’s comment in her concurring opinion in Davila, in which she drew attention to the Government’s suggestion that ERISA “as currently written and interpreted, may allo[w] at least some forms of ‘make-whole’ relief against a breaching fiduciary in light of the general availability of such relief in equity at the time of the divided bench.” Id. at 2504 (internal quotations omitted). (We note that in Davila, as here, the respondents had declined the opportunity to amend their state-law complaints to add ERISA claims, id. at 2502-03 n.7, but it appears that no one argued to the Court that this step was unnecessary, and it thus had no occasion to reach the point we have discussed in this opinion.)"

 

Supreme Court of the United StatesDetail of West Pediment above main entrance to Supreme Court
 

Arkansas Dept. of Health and Human Servs. v. Ahlborn

05/01/06

 

"Held: Federal Medicaid law does not authorize ADHS to assert a lien on Ahlborn’s settlement in an amount exceeding $35,581.47, and thefederal anti-lien provision affirmatively prohibits it from doing so.Arkansas’ third-party liability provisions are unenforceable insofaras they compel a different conclusion. Pp. 9–23......"

 

Sereboff v. Mid Atlantic Medical Services, Inc.

05/15/06

 

"Held: Mid Atlantic’s action properly sought "equitable relief" under §502(a)(3). Pp. 3–11......"

 

Aetna Health Inc. v. Davila

06/21/04

Opinion of the Court

 

"Held: Respondents’ state causes of action fall within ERISA§502(a)(1)(B), and are therefore completely pre-empted by ERISA §502 and removable to federal court. Pp. 4–20."

 

"We hold that respondents’ causes of action, brought to remedy only the denial of benefits under ERISA-regulated benefit plans, fall within the scope of, and are completely pre-empted by, ERISA §502(a)(1)(B), and thus removable to federal district court. The judgment of the Court of Appeals is reversed, and the cases are remanded for fur-ther proceedings consistent with this opinion.7 It is so ordered."

"7  The United States, as amicus, suggests that some individuals in respondents’ positions could possibly receive some form of “make-whole” relief under ERISA §502(a)(3). Brief for United States as Amicus Curiae 27, n. 13. However, after their respective District Courts denied their motions for remand, respondents had the opportu-nity to amend their complaints to bring expressly a claim under ERISA §502(a). Respondents declined to do so; the District Courts therefore dismissed their complaints with prejudice. See App. 147–148; id., at 298; App. B to Pet. for Cert. in No. 02–1845, pp. 34a–35a; App. B to Pet. for Cert. in No. 03–83, p. 40a. Respondents have thus chosen not to pursue any ERISA claim, including any claim arising under ERISA §502(a)(3). The scope of this provision, then, is not before us, and we do not address it."

GINSBURG, J., concurring

"The Government notes a potential amelioration. Recog-nizing that “this Court has construed Section 502(a)(3) not to authorize an award of money damages against a non-fiduciary,” the Government suggests that the Act, as currently written and interpreted, may “allo[w] at least some forms of ‘make-whole’ relief against a breaching fiduciary in light of the general availability of such relief in equity at the time of the divided bench.” Brief for United States as Amicus Curiae 27–28, n. 13 (emphases added); cf. ante, at 19 (“entity with discretionary authority over benefits determinations” is a “plan fiduciary”); Tr. of Oral Arg. 13 (“Aetna is [a fiduciary]—and CIGNA is for purposes of claims processing.”). As the Court points out, respondents here declined the opportunity to amend their complaints to state claims for relief under §502(a); the District Court, therefore, properly dismissed their suits with prejudice. See ante, at 20, n. 7. But the Govern-ment’s suggestion may indicate an effective remedy others similarly circumstanced might fruitfully pursue.

Congress . . . intended ERISA to replicate the core principles of trust remedy law, including the make-whole standard of relief.” Langbein 1319. I anticipate that Congress, or this Court, will one day so confirm."

ERISAclaim.com Comments (06/21/2004)

 

    On June 21, 2004, Supreme Court made another landmark ruling on managed-care and ERISA. As I predicted on April 28, 2004, this ruling will affirm long-standing position of court interpretation of the ERISA preemption of medical malpractice claims with punitive damages in state court, the high court also makes another unprecedented interpretation of equitable relief under ERISA as "make-whole" relief as consequential damage remedies, compared to "contractual damages" only remedies under ERISA, although the respondent declined to amend claims to seek such consequential damage relief, as pointed out by the court.

Contrary to mainstream reading of this supreme court ruling, that HMO or ERISA plan cannot be sued in state court for medical malpractice, bad faith or consumer fraud for state remedies and punitive damages, Supreme Court has made it clear that the "make-whole" relief will be available if the issue is before the court , and will be so confirmed (Justice Ginsburg).

The new ERISA era is here today, although no punitive damages available in state court, ERISA plans, fiduciaries and plan administrators can be sued for pain and suffering, lost wages , and any compensable damages , as well as attorney fees under "make-whole" relief in federal court instead of state court. Justice Ginsburg, in her concurring opinion, has made this point so clear that any concerned ERISA practitioners couldn't misunderstand:

"Congress . . . intended ERISA to replicate the core principles of trust remedy law, including the make-whole standard of relief." Langbein 1319. I anticipate that Congress, or this Court, will one day so confirm."

Hopefully this ruling will alert employers, ERISA plans, fiduciaries and managed-care organizations about plan's NEW consequential damage liabilities and faithfully fulfilling plan's fiduciary obligations by complying with ERISA claim regulations to minimize ERISA plan's legal and financial liabilities and to make ERISA claim administration and appeal process practical and meaningful as they argued in this case. And this ruling should also serve as a wakeup call for health care providers, American workers and their attorneys that except for punitive damages, federal court will provide new remedies, unavailable before, to compensate any consequential damages as "make-whole" relief if ERISA claim regulations are closely followed in pursuing healthcare claims under ERISA.

 

 

Overview: Aetna v. Davila Decision and Its Consequences (PDF) (ERISA Industry Committee)

3 pages. Excerpt: "The language in the concurring opinion offered by Justice Ginsberg, and joined by Justice Breyer, may ultimately be as significant for major employers as the Court decision......Finally, the concurrence turns to the Brief for United States as Amicus Curiae in this case, in which the Government notes that ERISA as currently written and interpreted, may "allo[w] at least some forms of 'make-whole' relief against a breaching fiduciary in light of the general availability of such relief in equity at the time of the divided bench". (emphasis added in the concurrence). The concurrence suggests that pursuit of fiduciary claims under §502(a) of ERISA may be "an effective remedy others similarly situated might fruitfully pursue"

Overview: Aetna Health Inc. v. Davila (Groom Law Group)

Excerpt: "We note, however, that a concurring opinion in Davila suggests that some form of "make whole" relief (e.g., damages) might be "appropriate equitable relief" under ERISA section 502(a)(3). This discussion was prompted by a U.S. Department of Labor amicus brief and likely will prompt the next wave of litigation as plaintiffs continue to seek damages in excess of the limited relief available under ERISA section 502(a)(1)(B)."

Supreme Court Ruling on Health Care Claims Raises Important Policy Issues: American Benefits Council Responds to Critics of Today's Davila, Calad Rulings (June 21, 2004)

"These review procedures are available under ERISA to help patients get the care they deserve, quickly and without having to resort to costly and lengthy legal procedures. Clearly, a speedy and factual review aided by the expertise of the physicians involved with these two cases could have avoided the need for the courts to be involved at all," Klein said.

"ERISA is intended to protection patients, not enrich plaintiffs' attorneys. If the objective is to ensure healthy and safe outcomes for patients, then certainly efficient review of claims disputes under ERISA, not inviting litigation, is the way to go," Klein added."

ERISAclaim.com Comments (06/21/2004)

"Clearly, a speedy and factual review aided by the expertise of the physicians involved with these two cases could have avoided the need for the courts to be involved at all," Klein said."

 

This could be true only if ERISA claim regulations were educated, complied and enforced in this country in past 30 years, practically and meaningfully (Aetna Video Shows ERISA Patients Mistreated):

 

  1. Managed care industry, MCO and physicians have no clue for 30 years about ERISA claim regulation, no one uses, complies or enfornces ERISA claim regulation in past 30 years;

  2. Almost all ERISA plans have anti-assignment clause to prohibit physicians from participating ERISA appeals, Physicians' Multispecialty v. The Health.

  3. ERISA has been around for almost 30 years, and new ERISA claim regulation went into effect for 2 years, no one, except for Dr. Jin Zhou & ERISAclaim.com, offered any ERISA claim appeal educations to MCO's, providers and ERISA plans.

 

"ERISA is intended to protection patients, not enrich plaintiffs' attorneys. If the objective is to ensure healthy and safe outcomes for patients, then certainly efficient review of claims disputes under ERISA, not inviting litigation, is the way to go," Klein added."

 

  1. Only time we talk about "efficient review of claims disputes under ERISA" is when disastrous events like these happened to show the importance of ERISA claim regulation, then the entire country never worked on how to ensure "efficient review of claims disputes under ERISA" (Aetna Video Shows ERISA Patients Mistreated);

  2. When this country is facing the worst healthcare crisis, governments, employers, healthcare providers and the industry must put money and practice to where our mouths are: ERISA Claim Regulations education, compliance and enforcement;

  3. Only when there is "efficient review of claims disputes under ERISA" and ERISA is working practically and meaningfully, "then certainly efficient review of claims disputes under ERISA, not inviting litigation, is the way to go,"

  4. Otherwise, as THE ERISA INDUSTRY COMMITTEE correctly concluded from this Supreme Court ruling for the industry:
     

    "Although the decision is a major preemption victory for health plans, Justices Ginsberg and Breyer's concurrence is fueling efforts in Congress to amend ERISA and either reverse the decision as it affects preemption or provide for a damages remedy in ERISA. In response to the decision, Congressman John Dingell, Ranking Member of the Committee on Energy and Commerce, has reintroduced the Patients' Bill of Rights to allow patients to sue health care plans under state law. It seems unlikely that employer plans, including self funded plans, will escape this latest effort to subject them to new remedies and litigation." (ERIC Analysis of Aetna v. Davila)

ERISAclaim.com Comments (06/22/2004)

"Clas-sifying any entity with discretionary authority over bene-fits determinations as anything but a plan fiduciary would thus conflict with ERISA’s statutory and regulatory scheme." (Aetna Health Inc. v. Davila, p19)

This may indicate that any party makes appeal decisions could be sued as a plan fiduciary and liable for "make-whole" relief.

 

The Davila Supreme Court Case and the Future of Health Plan Administration (Mintz Levin)

Excerpt: "It is not often that we see a unanimous Supreme Court decision ... This Mintz Levin Publication discusses the consolidated cases of Aetna Health Inc. v. Davila and CIGNA Healthcare of Texas, Inc. v. Calad in which the Court unanimously ruled that the Texas Patient's Bill of Rights Law is preempted by [ERISA] to the extent it attempts to regulate or dictate what is covered by an ERISA-covered group health plan."

ERISA Update: the Supreme Court Texas Decision and Other Recent Developments (PDF) (AcademyHealth)

7 pages. Excerpt: "The purpose of the brief is to explore the U.S. Supreme Court's June 2004 decision that ERISA preempts the Texas HMO liability law and its effects on other state health plan liability laws. The brief also examines implications of ERISA preemption for state health insurance regulation, 'pay or play' health coverage laws, and premium assistance programs."

ERISA Fiduciary Class Action filed for "Equitable Relief"?

PRAYER For RELIEF

"I. An order for equitable restitution and other appropriate equitable monetary relief against defendants."

 

Keller Rohrback L.L.P. Announces 401(k) Breach of Fiduciary Class Action Against Cardinal Health, Inc.

"SEATTLE, Aug. 12, 2004 (PRIMEZONE) -- Keller Rohrback L.L.P. (www.erisafraud.com) has filed a 401(k) Breach of Fiduciary Duty class action in the United States District Court for the Southern District of Ohio on behalf of participants and beneficiaries of the Cardinal Health Profit Sharing, Retirement and Savings Plan and the Syncor International Employees' Savings and Stock Ownership Plan (the "Plans"), who were invested in Cardinal Health Shares through the Plans between October 24, 2000 and the present (the "Class Period").

US Supreme Court Visits ERISAclaim.com


A visitor from user.
supreme-court.gov (208.253.84.20)
arrived from www.google.com 2560.503-1(h)(2)(iv) 1-10,
and visited www.erisaclaim.com/what's_new.htm
at 11:57:03 AM on Friday, November 21, 2003.
This visitor used Mozilla/4.0 (compatible; MSIE 5.5; Windows NT 5.0).

 

supreme-court.gov Google Search Results: 2560.503-1(h)(2)(iv)  = www.erisaclaim.com as No. 6 & No. 7  results on November 21, 2003.

 

supreme-court.gov search word: "2560.503-1(h)(2)(iv) 1-10", which is related to the following  ERISA Regulation:

 

ERISA CFR 2560.503-1 (h)(2)(iv) "Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination."

 

ERISAclaim.com Comments:

 

ERISA § 2560.503-1(h) is the most important part of ERISA claim regulation, this section requires every ERISA plan to establish and maintain an appeal procedure and the appeal has to be handled and decided only by "appropriate named fiduciary of the plan", instead of managed-care contracted middlemen, and the specific paragraph that US Supreme Court searched for, § 2560.503-1(h)(2)(iv), requires the plan to conduct a full and fair review by de novo standard at each appeal level. For more specific information, please refer to following paragraphs and different pages of this web site.

 

United States Supreme Court did use, and will probably more often utilize, the Internet and hyperlinks in its court rulings. In its recent decision in Black & Decker Disability Plan v. Nord  Decided 05/27/2003, the Supreme Court used Internet hyperlinks to cite and refer DOL FAQ B-4:

"It is the Secretary of Labor’s view that ERISA is best served by “preserv[ing] the greatest flexibility possible for . . . operating claims processing systems consistent with the prudent administration of a plan.” Department of Labor, Employee Benefits Security Administration, http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html, Question B–4 (as visited May 6, 2003) (available in Clerk of Court’s case file). Deference is due that view."

Supreme Court Collection home

Supreme Court ERISA Watch

 

    Unless Congress Rewrites ERISA, Federal Court Ruling Is the Only and Ultimate Answer to Interpretation of Mysterious ERISA Statutes and Regulations for Our Managed Care Claim Denials and Disputes. Case Law in ERISA Develops Every Day. Without Understanding of ERISA Case Law, One Will Never Truly Understand What ERISA Really Means in  Dollars and Sense of Health-care Benefits Dispute in 80% of health-care claims or 60% of health expenditures in the U. S..

   For Any Claim Denial and Appeal Process, the Superpower and Protections Only Come from Truly Understanding of ERISA Statutes and Regulations, Ever Changing Case Laws As Well As Practical Implementation of Most Recent Court Interpretation of the ERISA Statutes and Regulations.

            
A $1.0 Trillion Nuclear Solution to Our Nation's Health-care Crisis

 

US Supreme Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21, 2003
 


Post Supreme Court Davila Scoop:

ERISA Pre-emption of State Laws in Healthcare

 

01-10831 10/12/2004 Roark vs. Humana Inc


United States Court of Appeals

Fifth Circuit

F I L E D

October 12, 2004

Charles R. Fulbruge III

Clerk

In the

United States Court of Appeals

for the Fifth Circuit

_______________

m 01-10891

_______________

RUBY R. CALAD,

Plaintiff-Appellant-

Cross-Appellee,

WALTER PATRICK THORN,

Plaintiff-Cross-Appellee,

VERSUS

CIGNA HEALTHCARE OF TEXAS, INCORPORATED,

DOING BUSINESS AS HEALTHSOURCE,

DOING BUSINESS AS CIGNA CORPORATION,

Defendant-Appellee,

AETNA U.S. HEALTHCARE;

AETNA U.S. HEALTHCARE OF NORTH TEXAS, INC.,

Defendants-Appellees-

Cross-Appellants.

* * * * * * * * * * * * * * *

_______________

m 01-10905

_______________

JUAN DAVILA,

Plaintiff-Appellant,

VERSUS

AETNA U.S. HEALTHCARE, INC.;

AETNA U.S. HEALTHCARE OF NORTH TEXAS, INC.,

Defendants-Appellees.

_________________________

Appeals from the United States District Court

for the Northern District of Texas

Dist. Ct. m 3:00-CV-2368-D (5th Cir. Nos. 01-10891, 01-10905)

Dist. Ct. m 3:00-CV-2693-H (5th Cir. m 01-10891)

_________________________

ON REMAND FROM THE SUPREME COURT OF THE UNITED STATES

 

Before SMITH and BENAVIDES,

 

Circuit Judges.*

 

PER CURIAM:

    The Supreme Court reversed and remanded this panel’s opinion. See Roark v. Humana, Inc., 307 F.3d 298 (5th Cir. 2002), reversed  sub nom. Aetna Health Inc. v. Davila, ___

U.S. ___, 124 S. Ct. 2488 (2004). We requested and have received letters from the parties advising of their respective positions regarding the appropriate action to be taken by this court on remand. The parties appear to agree that this litigation is at an end. Plaintiffs Calad and Davila have nonsuited their actions in state court.

     Accordingly, the appeals are DISMISSED. All costs are taxed against the plaintiffs.

* Judge Parker was a member of this panel but resigned from the court after the initial opinion was issued. This matter is now decided by a quorum. See 28 U.S.C. § 46(d).

 

 

 

CICIO v VYTRA HEALTHCARE

Cicio v. Vytra Healthcare (pdf)


Cicio v. Vytra Healthcare

2nd Cir. 09/24/2004

 

"DISCUSSION


The facts of this case are set forth in detail in our earlier opinion. We need not rehearse them here.


In Aetna Health Inc., the Supreme Court declared that "any state-law cause of action that duplicates, supplements, or supplants the [Employee Retirement Income Security Act of 1974 ("ERISA")] civil enforcement remedy conflicts with the clear congressional intent to make the ERISA remedy exclusive and is therefore pre-empted." 124 S. Ct. at 2495. "Congress' intent to make the ERISA civil enforcement mechanism exclusive would be undermined if state causes of action that supplement the ERISA § 502(a) remedies were permitted, even if the elements of the state cause of action did not precisely duplicate the elements of an ERISA claim." Id. at 2499-2500......

 

CONCLUSION

Accordingly, we vacate our previous decision in this matter and affirm the district court's dismissal of Ms. Cicio's complaint."

 

Barber v. Unum Life Ins Co

3rd Cir. 09/07/2004

 

"Because we hold 42 Pa. C.S. § 8371 is conflict preempted by ERISA, or alternatively expressly preempted under ERISA § 514(a), we will reverse the judgment of the District Court and remand with instructions to dismiss Barber’s bad faith claim."

 

Overview: 3rd Circuit Boots Theory Allowing Bad-Faith ERISA Litigation (Law.com)

 

LAND v CIGNA HEALTHCARE OF FLORIDA
[07/30/03, 11th Cir.]

Robbie Lee Land v. Cigna Healthcare of Florida

11th Cir.

(August 27, 2004)

"ON REMAND FROM THE SUPREME COURT OF THE UNITED STATES

Before MARCUS and WILSON, Circuit Judges, and RESTANI , Judge. *

PER CURIAM:

 

After we issued our decision in this case on July 30, 2003, Land v. CIGNA Healthcare of Florida, 339 F.3d 1286 (11th Cir. 2003), the Supreme Court vacated and remanded for further consideration in light of its recent decision in Aetna Health Inc. v. Davila, 542 U.S. ----, 124 S. Ct. 2488 (2004). After carefully reviewing Davila, we find that Land’s state law malpractice claims against his health maintenance organization (“HMO”) were preempted by Section 502 of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001-1461."

 

Eleventh Circuit Court Nixes State Malpractice Lawsuit Against ERISA HMO (RIA Pension & Benefits Week)

 

US Health Care Gaps Kill 79,000 People a Year, Report Shows (Bloomberg - United States)

"Sept. 23 (Bloomberg) -- Disparities in the U.S. health-care system result in up to 79,000 premature deaths each year because of a lack of preventative treatments and care for chronic conditions like diabetes, according to the National Committee for Quality Assurance."

The State of Health Care Quality, 2004: Industry Trends and Analysis (PDF) (National Committee for Quality Assurance)

61 pages. Excerpt: "NCQA's annual State of Health Care Quality report ... found that nearly 66.5 million avoidable sick days and more than $1.8 billion in excess medical costs can be traced to the health care system's routine failure to provide needed care."

 

ERISA Shield Explosion!!!

ERISA Patient's Bill of Right from Supreme Court

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

04/28/2004


U.S. SUPREME COURT
Docket for 03-83
 

ORAL ARGUMENT TRANSCRIPTS

(Summary of Oral Arguments)

Based on ORAL ARGUMENT TRANSCRIPTS in Aetna Health Inc. v. Davila, it is my prediction and forward-looking conclusion that ERISA Shield for 29 years be 95% exploded!

 

This will change entire health care and litigation landscape.

 

ERISA NEW remedy or relief will include:

 

  1. Not only contractual damage as in the past;

  2. But also "make whole" relief including compensatory damages, such as pain and suffering and attorney fees;

  3. However, no punitive available as contemplated by the most;

  4. While only 3% all civil cases go to trial, to 6% of which were awarded punitive damages anyway in nation's 75 big counties in 2001. (DOJ/BJS)

ORAL ARGUMENT TRANSCRIPTS

 

"QUESTION: Yes. And so, as a fiduciary they're -- they are analogous to a trustee, at least, the government said, if I read their footnote 13 right, that back in the old days when there was -- was a division of the bench, that one of the remedies available against a trustee would be in the nature of make whole relief that would put the beneficiary in the position he would have been in if the trustee had not committed the breach of trust." (page 13)

 

"QUESTION: No, but the whole thing would work if we could do that, wouldn't it? I mean, if we could get Mertens consistent with what Justice Ginsberg just read, then you would provide people who are hurt, in the way these plaintiffs were hurt, with a remedy. It wouldn't be punitive damages, but they would be made whole. So, if you are right in that this is basically a -- this is basically a claims decision and you shouldn't give punitives and others for the incorrect making of a claims decision. But the hole in this is that then the woman gets nothing or virtually nothing and, if we could reconsider that part, it would all work, wouldn't it?" (page 13)

 

"QUESTION: Lest we be too sanguine about the application of that law in this context, I don't know any equitable cases that would consider make whole relief to be giving -- where what is at issue is merely the payment -- the failure to pay money, refusal to pay money. Make whole relief would give you what you would have done with that money if you had gotten it. That's very strange." (page 15)

 

"QUESTION: But it would all work, you see, if I have a trust, the trust is supposed to buy me an insurance policy, and through total fault of the trust it doesn't, and the house burns down, the equitable relief appropriate would be consequential damages of the value of the house. Now, if that were an appropriate case, other equitable relief, this whole thing would work and you wouldn't be having to fill a vacuum." (page 25)

 

RUSH PRUDENTIAL HMO, INC. v. MORAN [00-1021]
 

(Rush) "It is, in fact, the Plan Administrator" (footnote 3)

 

As lower federal courts have erroneously interpreted ERISA preemption for decades, Supreme Court clarifies ERISA preemption for the first time, at the same time, Supreme Court clarifies and interprets ERISA as to how to identify and determine the plan administrator status, as most lower courts have erroneously interpreted ERISA for decades to consider the plan sponsor as the plan administrator when the plan administrator has granted the discretion to another party and has never exercised such discretionary authority.

ERISAClaim.com Comment: (click here for details)

 

 

 

RAYMOND B. YATES, M.D., P.C. PROFIT SHARINGPLAN V. HENDON

(RAYMOND B. YATES, M.D., P.C. PROFIT SHARINGPLAN V. HENDON)

Argued January 13, 2004–Decided March 2, 2004

U.S. Supreme Court

  02-458. Raymond B. Yates, M.D., P.C., Profit Sharing Plan v. Hendon 01/13/04

 

"Held: The working owner of a business (here, the sole shareholder and president of a professional corporation) may qualify as a “participant” in a pension plan covered by ERISA. If the plan covers one or more employees other than the business owner and his or her spouse, the working owner may participate on equal terms with other plan participants. Such a working owner, in common with other employees, qualifies for the protections ERISA affords plan participants and is governed by the rights and remedies ERISA specifies. Pp. 8—20."

 

ERISAclaim.com Comments:

 

  1. Supreme Court clarifies the definition of ERISA plan, even one employee, that's an ERISA plan;

  2. A plan sponsor, employer or sole shareholder is a participant/employee of an ERISA plan, entitled to rights and protections in welfare and pension plans afforded by ERISA;

  3. An employer in an ERISA plan may not sue an insurance company and/or ERISA plan for bad faith and punitive damages in ERISA benefits disputes arguing that an employer is not an employee of an ERISA plan, not subject to ERISA preemption, as reported recently in many states and jurisdictions.

 

 

Supreme Court Finds That Working Business Owner Is ERISA-Protected Participant When Plan Covers Other Employees (EBIA.com)

 

Aetna v. Davila  

 

CNN.com - Justices appear split on HMO issue - Mar 24, 2004

 

'HMO horror story' comes to high court in patient law test  - USATODAY.com

"Patients in Calad's position could appeal an HMOs decision internally, pay for the additional medical care themselves or sue someone else — a doctor, or a hospital most likely — several justices suggested Tuesday."

 

Supreme Court to rule on patients' rights
Miami Herald, FL - Nov 3, 2003

 

Supreme Court Considers Limits on Patients' Right to Sue Insurers (KRT Wire)

 

Both sides ready for HMO liability fight  (AMNews)

 

Bush Turns His Back on Fight for Patients' Rights (LA Times)

* As governor, he sought accountability for HMOs. Now he favors industry immunity.

"But instead, the administration is trying to shield health plans by stealth from accountability for denying coverage.

Were Bush to propose publicly that Congress immunize HMOs from suits for withholding care, there would surely be a firestorm of public anger. But his administration is on the verge of achieving the same result from the Supreme Court, almost without notice, veiled by the arcane language of the law."
 

SUPREME COURT Docket for 02-1845
Aetna v. Davila
 

 

For petitioner Cigna Healthcare of Texas, Inc.
and Cigna Health Inc.


Respondent's brief

Reply brief for Aetna Health Inc.; Appendix

 

Reply brief for Cigna Healthcare of Texas, Inc.

 

(Fifth Circuit) (01-10905.cv0) (PDF)

No. 02-1845: Aetna Health, Inc. v. Davila - Amicus (Merits)
View PDF Version (www.usdoj.gov)

American Association of Health Care Plans, Inc., et al. (Petition) [PDF]

 

Amicus Brief by Families USA in Supreme Court HMO Liability Case (Families USA)

 

Amicus Brief by AMA & TMA....

 

SUPREME COURT Docket for 03-83 
CIGNA v. Calad

(
Fifth Circuit) (01-10891.cv0) (PDF)

 

ORAL ARGUMENT TRANSCRIPTS

  02-1845. Aetna Health Inc. v. Davila 03/23/04

 

ERISA Shield Explosion!!!

ERISA Patient's Bill of Right from Supreme Court

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

04/28/2004


U.S. SUPREME COURT
Docket for 03-83
 

ORAL ARGUMENT TRANSCRIPTS

(Summary of Oral Arguments)

Based on ORAL ARGUMENT TRANSCRIPTS in Aetna Health Inc. v. Davila, it my prediction and forward-looking conclusion that ERISA Shield for 29 years be 95% exploded!

 

This will change entire health care and litigation landscape.

 

ERISA NEW remedy or relief will include:

 

  1. Not only contractual damage as in the past;

  2. But also "make whole" relief including compensatory damages, such as pain and suffering and attorney fees;

  3. However, no punitive available as contemplated by the most;

  4. While only 3% all civil cases go to trial, to 6% of which were awarded punitive damages anyway in nation's 75 big counties in 2001. (DOJ/BJS)

ORAL ARGUMENT TRANSCRIPTS

 

"QUESTION: Yes. And so, as a fiduciary they're -- they are analogous to a trustee, at least, the government said, if I read their footnote 13 right, that back in the old days when there was -- was a division of the bench, that one of the remedies available against a trustee would be in the nature of make whole relief that would put the beneficiary in the position he would have been in if the trustee had not committed the breach of trust." (page 13)

 

"QUESTION: No, but the whole thing would work if we could do that, wouldn't it? I mean, if we could get Mertens consistent with what Justice Ginsberg just read, then you would provide people who are hurt, in the way these plaintiffs were hurt, with a remedy. It wouldn't be punitive damages, but they would be made whole. So, if you are right in that this is basically a -- this is basically a claims decision and you shouldn't give punitives and others for the incorrect making of a claims decision. But the hole in this is that then the woman gets nothing or virtually nothing and, if we could reconsider that part, it would all work, wouldn't it?" (page 13)

 

"QUESTION: Lest we be too sanguine about the application of that law in this context, I don't know any equitable cases that would consider make whole relief to be giving -- where what is at issue is merely the payment -- the failure to pay money, refusal to pay money. Make whole relief would give you what you would have done with that money if you had gotten it. That's very strange." (page 15)

 

"QUESTION: But it would all work, you see, if I have a trust, the trust is supposed to buy me an insurance policy, and through total fault of the trust it doesn't, and the house burns down, the equitable relief appropriate would be consequential damages of the value of the house. Now, if that were an appropriate case, other equitable relief, this whole thing would work and you wouldn't be having to fill a vacuum." (page 25)

 

 

ERISAclaim.com Comments (02/09/2004):

 

After reviewing briefs from petitioner and respondent and Merits from U.S. government, the following are my comments:

 

A. ERISA does not preempt respondent's state claim as Congress has never intended to federalize medical malpractice or medical decisionmaking as interpreted in recent Supreme Court ruling in Pegram et al. v. Herdrich.

 

Any reliance on any Supreme Court ruling, Pilot Life Insurance Co. v. Dedeaux, prior to Pegram et al. v. Herdrich is misplaced as Supreme court interpretation, in Pegram et al. v. Herdrich, of Congress intention in enacting ERISA in 1974 could never have dreamed to make mixed medical decision by a fiduciary that could harm plan participant.

 

""we think Congress did not intend Carle or any other HMO to be treated as a fiduciary to the extent that it makes mixed eligibility decisions acting through its physicians." Pegram et al. v. Herdrich

 

B. Petitioner and U.S. argued that Pegram et al. v. Herdrich is only intended or applicable to an HMO owned and operated by physician, and appeals court misread Pegram, but this argument is directtly contrary to Supreme Court plain English interpretation in Pegram et al. v. Herdrich:

 

""we think Congress did not intend Carle or any other HMO to be treated as a fiduciary to the extent that it makes mixed eligibility decisions acting through its physicians."

 

In this sentence, "Carle" refers to an HMO owned and operated by physicians. "any other HMO" refers to any and other HMO regardless who owned and operated, as long as "it makes mixed eligibility decisions acting through its physicians", it (HMO) was not intended by congress to be treated as a fiduciary because:

 

"(b) Under ERISA, a fiduciary is someone acting in the capacity of manager, administrator, or financial adviser to a 'plan,'"

 

In " it makes....", it refers to an HMO. "Acting through its physicians" means carrying out mixed decisions through its physicians instead of HMO has to be owned by physicians.

 

"Held: Because mixed treatment and eligibility decisions by HMO physicians are not fiduciary decisions under ERISA" is applicable to any and other HMO. The appeals court reliance on Supreme Court ruling in Pegram et al. v. Herdrich is not misplaced or misread.

 

Both petitioner and US argued that Pegram et al. v. Herdrich is only applicable to an HMO owned by physicians, respondent did not specifically explained the above captioned with only objections through a footnote.

 

C. Petitioner does not deny it made mixed treatment and eligibility decisions.

 

"a "medi-cally necessary" procedure or treatment often is defined as one that is not only medically appropriate, but also more cost-effective than any other""

 

"Generally, such definitions incorporate economic considerations as well as medical ones:"

 

As to hospital discharge decisionmaking in determining the number days days to discharge, unless the PLAN's SPD has a number of days as a cap for that diagnosis and treatment procedure, it's pure medical, non-fiduciary decision under Utilization Review.

 

D. Petitioner cited New ERISA regulation, section 503-1 (k) (2), in arguing that state Insurance law requiring utilization review shall have no jurisdiction on decisions made by the insurer, plan fiduciary and employer, asserting that Texas HMO liability act shall have no jurisdiction over a fiduciary, but this argument is just contradictively made because new provision (k) of ERISA regulation is mainly intended to provide no ERISA preemption of state law requiring utilization review in medical decisionmaking in utilization review and such a state law shall not prevent application of new ERISA claim regulation as long as a decision is made by an insurer and the plan fiduciary, and new regulation, § 2560.503-1(h)(3)(iii), requires a plan named fiduciary consult with a healthcare professional in making medical judgment such as in this case, medication and hospital discharge decisions. An appropriate healthcare professional is defined as some one who is licensed in the same state to practice same medicine, but petitioner made that medical decision as a healthcare professional.

 

E. If ERISA is not intended by Congress in 1974 to treat a mixed treatment and eligibility decision as a fiduciary decision, and a mixed treatment and eligibility decision is a nonfiduciary decisionmaking as interpreted by Supreme Court in Pegram et al. v. Herdrich, and if no dispute is made on the material fact that mixed treatment and eligibility decisions were made by the petitioner, ERISA does not preempt respondent's alleged state tort claim. As to whether Texas HMO liability act is preempted by ERISA, the issue is moot in dismissing respondent claims. And if Texas HMO liability act has no impermissible connection to the ERISA plan, as to benefits fiduciary decisionmaking, and it regulates only quality of medical care in protecting public health and safety, it will not be preempted by ERISA.

 

ERISAClaim.com Comment (03/20/2004) on Reply brief for Aetna Health Inc. :

 

My Comments B, made on 02/09/2004 before Aetna's Reply Brief as above captioned, pointed out that "respondent did not specifically explained the above captioned with only objections through a footnote." BUT I provided The "response to this distinction other than the question-begging assertion that HMOs “should not be permitted to avoid malpractice liability” by adopting this structure." Please review my "Comment B" for details.

Reply brief for Aetna Health Inc. (Page 8):

"3. To sow confusion where there is none, Davila and his amici recite this Court’s reference in Pegram to a “puzzling issue of preemption” that justified reluctance to infer an ER-ISA case of action in that case. Resp. Br. 28 (quoting Pe-gram v. Herdrich, 530 U.S. 211, 236 (2000)) (internal quota-tion marks omitted). But however “puzzling” the issue might be in the context of the “mixed” decisions made by a physician owner of a group-model HMO (or a staff-model HMO, where treating physicians, like the defendant in Pegram, also make both coverage and treatment decisions), the issue is entirely straightforward where, as here, coverage and treatment are clearly separated. Davila offers no response to this distinction other than the question-begging assertion that HMOs “should not be permitted to avoid malpractice liability” by adopting this structure. Resp. Br. 36. But by engaging only in benefits administration—which ERISA regulates exclusively, leaving no room for additional state-law medical standards—Aetna has never entered the sphere of traditional medical practice that might justify subjecting it to state-law malpractice liability.7 That sphere is left to physicians.


7 As both Davila and the Texas Attorney General state, the THCLA on its face applies even when the HMO provides no medical treatment, if the plaintiff shows that the HMO’s coverage."

If this argument is valid, then the whole Davila is not about ERISA pre-emption, as Davila is not about ERISA.

 

Davila is not about "to persuade this Court to modify or abandon Pilot Life Insurance Co. v. Dedeaux, 481 U.S. 41 (1987), and its progeny." (Reply Brief page 1), Davila is not about Pilot Life at all, Davila is about Pegram, "Because mixed treatment and eligibility decisions by HMO physicians are not fiduciary decisions under ERISA". Davilia is not about ERISA, "not fiduciary decisions under ERISA" when "mixed treatment and eligibility decisions" are made by any HMO's, ultimately carried out by physicians.

 

""we think Congress did not intend Carle or any other HMO to be treated as a fiduciary to the extent that it makes mixed eligibility decisions acting through its physicians." Pegram

 

"it makes mixed eligibility decisions" = "Carle or any other HMO" makes mixed eligibility decisions"

 

then "acting through its physicians."

 

"any other HMO" (it could be any types of HMO) could be any one who/it makes final mixed decisions but treating physicians, otherwise there could be no denials in any HMO's if treating physicians make final decisions, while any treating decisions made by the plan in managed care setting have to be carried out by treating physicians and patients, yet this was misconstrued by petitioner as initial and final mixed decisions were completely made by treating physicians.

 

Therefore, Davila is not about Pilot Life but Pegram, not ERISA, no pre-emption.

 

However, Petitioner's argument that physicians and patients could have and should have appealed plan's denial decisions is not completely pointless, had ERISA plans and managed care industry in past 30 years followed ERISA claim procedures, established and maintained reasonable ERISA appeal procedures for physicians and patients.

 

No one in the country for 30 years knows how to do ERISA appeals, almost all physician's ERISA appeals were dismissed by courts on the ground of ERISA plan's anti-assignment provisions when petitioner argues that:

Reply brief for Aetna Health Inc. (Page 6):

"If physicians disagree with denials of coverage, they may provide the recommended care or services and pursue the ERISA beneficiaries’ rights to payment themselves, pursuant to the assignment of benefits taken at the outset of providing care. See, e.g., Decatur Mem’l Hosp. v. Conn. Gen. Life Ins. Co., 990 F.2d 925, 926-27 (7th Cir. 1993)."

and ERISA appeals were done for patients in the following fashion:

 

Aetna Video Shows ERISA Patients Mistreated

 

McDougall vs Pelchart, et al (Aetna, UPS)

 

And the leadership foreclosed meaningful ERISA appeals through ERISA adminstrative enforcement to avoid tort actions by patients:

 

[rules to be "self-enforcing"] & Leadership.

 

Employers and ERISA managed care industry must practically and meaningfully promote ERISA claim appeal educations, compliance and enforcement to use meaningful ERISA administrative appeal avenue to avoid Tort avenue to solve this conflict and the root of U.S. healthcare crisis with skyrocketing costs.

 

Had Davila and Dr. Lopez been afforded meaningful  ERISA Appeals by ERISA plans, this whole tort thing would never have happened.

 

ERISA Failure = Tort Actions = Healthcare Crisis

 

(end 03/20/2004)

 

ERISAclaim.com  Prophecy (11/17/2003):

 

The ruling from the Supreme Court will be that of Pegram + CICIO v VYTRA HEALTHCARE = Pegram II:

 

1. "Mixed treatment and eligibility decisions by HMO physicians are not fiduciary decisions under ERISA. (Pegram);

 

2. "Without regard to Mr. Cicio's "constellation of symptoms" but in the abstract", Davila and Calad's medical claim (medications & discharge) decisions are not fiduciary decisions under ERISA. (CICIO)--(How to draw the line between mix or pure?=mix!)

 

The consolidated Davila and Calad case will be Pegram II, a contributing factor for fixing EFS, ERISA Failure Syndrome and  determining factor to ERISA medical liability preemption.

 

 

Who Would Decide When to
Discharge A Patient
?
(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)


U.S. SUPREME COURT
Docket for 03-83
 

ORAL ARGUMENT TRANSCRIPTS (page 16-17 0f 49)

  02-1845. Aetna Health Inc. v. Davila 03/23/04

"QUESTION: Yes, but in the situation in the hospital case, there was no time to get relief. How could they -- how could they get relief from the denial of the extra day in the hospital between midnight and the next morning?

.....

 

QUESTION: And what does that mean in the hospital setting? And what -- was she going to file a complaint with the Department of Labor?

 

MR. FELDMAN: These claims can be made orally, again, if the exigencies require, and she could -- she didn't try -- as far as we know, no one made a phone call to the insurer and said can I get the extra benefits; she needs it. We don't know what the results of that would have been.

 

QUESTION: Well let's assume the case -- because your preemption item would cover even the most extreme case. Assume the case in which the patient and the doctor both called the agency and appealed and they said we're too busy, we can't handle it and it later determines they were -- did not exercise due care.

 

MR. FELDMAN: But then --

 

QUESTION: Why are you preempting the state providing a remedy for that situation?

 

MR. FELDMAN: That would have been itself a denial of their obligations under the Department's claim processing --claims processing procedures. But let me say there's also --

 

QUESTION: It would have been a denial, but it wouldn't have given her the extra day in the hospital?

 

MR. FELDMAN: Right, but there are other backstops for her getting the extra day in the hospital. She is, at that point, in the same position as anyone else who can't pay for another day in the hospital but they need it.

 

QUESTION: I understand.

 

MR. FELDMAN: It's up to her doctor, with whom she has a doctor patient relationship that's a consensual relationship for providing medical treatment. It's up to her doctor to decide when she should be discharged from the hospital and when she shouldn't."

 

 (Page 17-19)

 

JAMES A. FELDMAN, ESQ., Assistant to the Solicitor General, Department of Justice, Washington, D.C.; on behalf of the United States, as amicus curiae, supporting petitioners.

 

Who Can Be a Medical Reviewer under ERISA?
(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)


U.S. SUPREME COURT
Docket for 03-83
 

ORAL ARGUMENT TRANSCRIPTS (page 46 0f 49)

  02-1845. Aetna Health Inc. v. Davila 03/23/04

"QUESTION: Mr. Estrada, you can address what you would like but there are three points that have come up during the Respondent's presentation that I'd be interested with a response to.

 

Number one, is it true that the people who make the decisions for your client must be medical doctors in Texas?

 

MR. ESTRADA: Well it is true by virtue of DOL regulations which provide that no claim may be turned down without input from a medical professional in the relevant area"

New Federal Claim Regulation (Final Rule)

  1. "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)]

  2. "The term `health care professional' means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law." [page 70271 CFR § 2560.503-1(m)(7)]  

 

  • "medical doctors in Texas" = MD licensed to practice medicine in Texas for a Texas ERISA case;

  • "a medical professional in the relevant area" = relevant area of state laws in license jurisdiction, scope of practice and relevant local standard of care;

  • "licensed" = licensed by the State Government/licensing board;

  • "to perform" = to practice medicine or health care services in the State;

  • "specified health services" = medical procedures or services being reviewed or denied, instead of file review or insurance coverage reviews services;

  • "consistent with State law" = consistent with State laws where  the health care professional is legally licensed to practice medicine or health care services with respect to state jurisdictions,  scope of license and state local medical standard of care.

 

"The term `health care professional' means, in layman term,  a physician or other health care professional who is at least licensed in your state (and more, board certified too) to practice the specified/specific health services being reviewed or denied of your claims, consistent with your state law jurisdiction, scope of practice and local medical standard of care. Someone who is not licensed to practice the same health care services specified/denied in your claims is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).

 

Someone who is not licensed in your state to practice "specified health services" but who is merely registered under state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization Reviews (UR) is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).

 

    U.S. Supreme Court visited ERISAclaim.com in regard to ERISA § 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this No. one point. Click here for more coverage of Supreme Court Visiting at ERISAClaim.com.

 

 

Who Would Be A Fiduciary?
(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)


U.S. SUPREME COURT
Docket for 03-83
 

ORAL ARGUMENT TRANSCRIPTS (page 16-17 0f 49)

  02-1845. Aetna Health Inc. v. Davila 03/23/04

"MR. FELDMAN: I -- it's not clear to me whether it would, because it's not clear to me whether there was a fiduciary involved in this case. Neither of the claimants in this case, neither they -- the people who denied the benefits on behalf of the plans may or may not have been fiduciaries.

QUESTION: But, as Mr. Estrada just told us that, for these purposes, both Aetna and CIGNA would be fiduciaries.

 

MR. FELDMAN: They -- well, whether the -- you know, I frankly haven't thought about whether the plan itself would be a fiduciary...... "

 

 (Page 16-17)

 

JAMES A. FELDMAN, ESQ., Assistant to the Solicitor General, Department of Justice, Washington, D.C.; on behalf of the United States, as amicus curiae, supporting petitioners.

 

 

ERISA Shield Explosion?

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

PEGRAM et al. v. HERDRICH
U.S. Supreme Court,

Decided 06/12/2000

RUSH PRUDENTIAL HMO, INC. v. MORAN

U.S. Supreme Court,

Decided June 20, 2002

Kentucky Assn. of Health Plans, Inc. v. Miller

U. S. Supreme Court,

Decided: April 2, 2003

Aetna v. Davila

Docket for 02-1845
SUPREME COURT
SET FOR ARGUMENT Tuesday, March 23, 2004.

 

 

 

 

Black & Decker Disability Plan v. Nord (pdf)

U.S. Supreme Court, Decided 05/27/2003

 

 02-469. Black & Decker Disability Plan v. Nord 04/28/03

 

 

Excerpt  "Held: ERISA does not require plan administrators to accord special deference to the opinions of treating physicians.... [A]dministrators may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician. But courts have no warrant to require administrators ... to accord special weight to the opinions of a treating physician’s evaluation."

 

"In determining entitlement to Social Security benefits, the adjudicator measures the claimant’s condition against a uniform set of federal criteria. “[T]he validity of a claim to benefits under an ERISA plan,” on the other hand, “is likely to turn,” in large part, “on the interpretation of terms in the plan at issue.” Firestone Tire, 489 U. S., at 115. It is the Secretary of Labor’s view that ERISA is best served by “preserv[ing] the greatest flexibility possible for . . . operating claims processing systems consistent with the prudent administration of a plan.” Department of Labor, Employee Benefits Security Administration, http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html, Question B–4 (as visited May 6, 2003) (available in Clerk of Court’s case file). Deference is due that view."

 

ERISAclaim.com Comment: ERISA does not grant or require plan administrator/claim fiduciary with a rubber stamp to automatically reject or accept opinions from claimant's treating physicians, instead ERISA requires administrator/claim fiduciary to interpret particular terms of the plan at issue in accordance with ERISA prudent administration of the plan and obligated under fiduciary duties, specifically promulgated through new DOL Benefit Claims Procedure Regulation, Interpreted by DOL FAQ, B4, consistent decisionmaking requirement.

 

It is very important to note that U.S. Supreme Court now has clearly endorsed DOL's FAQ (New Guidance), effective for all ERISA plans after January 1, 2003, for its administrative interpretation of new Benefits Claim Procedure Regulation.

 

 

PACIFICARE HEALTH SYSTEMS, INC. v. BOOK

United States Supreme Court, Decided: April 7, 2003

 

  02-215. Pacificare Health Systems, Inc. v. Book 02/24/03

 

"Physicians' claims that managed-health-care organizations violated the Racketeer Influenced and Corrupt Organizations Act (RICO) can be compelled to arbitration. Questions as to remedial provisions in an arbitration agreement and availability of RICO treble damages are premature. (FindLaw.com)

 

ERISAclaim.com Comment:

This Supreme Court ruling will have profound impact on any provider and managed-care dispute, affecting every managed-care contract between healthcare providers, managed-care organizations, plan sponsors and managed-care networks. Due to current political atmosphere on tort reform initiatives nationwide, medical associations, hospital associations and physician organizations will not be able to realize any significance of this landmark ruling from Supreme Court in managed-care industry.

 

This ruling is expected to most likely render a death sentence for all of the class-action lawsuits by medical associations because arbitration is only limited to provider contract dispute with managed-care organizations and networks/insurers and subscribers/participants & beneficiaries/patients benefit disputes in subscriber tract of parallel class-actions representing 143 million Americans are dismissed.

 

Only solution to managed-care nightmares for this nation is to educate everyone on ERISA claim procedure and SPD regulations, to prevent, avoid, minimize and resolve any potential disputes through statutorily prescribed appeal procedures under ERISA.

 

Check out how this ruling makes difference in provider's class actions defense later as to compelling arbitration as a ground for dismissal.

 

Thomas/Kutell, MD v. BCBS, Case #03-21296 - Judge Dubé

 

Jun 18, 04 Plaintiffs' Second Amended Class Action Complaint

 

Jun 28, 04  Solomon:  First Amended Complaint - Class Action

 

 

 

Kentucky Assn. of Health Plans, Inc. v. Miller

United States Supreme Court, Decided: April 2, 2003

Kentucky Assn. of Health Plans v. Miller (Resources via Findlaw.com)
ERISA, Preemption of State Law, Health Insurance

 

  00-1471. Kentucky Assn. of Health Plans, Inc. v. Miller 01/14/03

 

 

U. S. Supreme Court unanimously ruled on April 02, 2003 that Kentucky any willing provider statutes are not preempted by ERISA, another landmark ruling in Managed Care Industry.


"Held: Kentucky's AWP statutes are "law[s] ... which regulat[e] insurance" under §1144(b)(2)(A). Pp. 3-12."

 

"Today we make a clean break from the McCarran-Ferguson factors and hold that for a state law to be deemed a "law . . . which regulates insurance" under §1144(b)(2)(A), it must satisfy two requirements. First, the state law must be specifically directed toward entities engaged in insurance. See Pilot Life, supra, at 50, UNUM, supra, at 368; Rush Prudential, supra, at 366. Second, as explained above, the state law must substantially affect the risk pooling arrangement between the insurer and the insured. Kentucky's law satisfies each of these requirements."

 

"Footnote 1   Both of Kentucky's AWP laws apply to all HMOs, including HMOs that do not act as insurers but instead provide only administrative services to self-insured plans. Petitioners maintain that the application to noninsuring HMOs forfeits the laws' status as "law[s] . . . which regulat[e] insurance." §1144(b)(2)(A). We disagree. To begin with, these noninsuring HMOs would be administering self-insured plans, which we think suffices to bring them within the activity of insurance for purposes of §1144(b)(2)(A). Moreover, we think petitioners' argument is foreclosed by Rush Prudential HMO, Inc. v. Moran, 536 U. S. 355, 372 (2002), where we noted that Illinois' independent-review laws contained "some overbreadth in the application of [215 Ill. Comp. Stat., ch. 125,] §4-10 [(2000)] beyond orthodox HMOs," yet held that "there is no reason to think Congress would have meant such minimal application to noninsurers to remove a state law entirely from the category of insurance regulation saved from preemption."

 

ERISAclaim.com Comment:

 

1. State any willing provider statutes, along with state independent review laws as ruled in Rush Prudential HMO, Inc. v. Moran and state utilization review laws, are not preempted by ERISA;

 

2. State Insurance Law ERISA Preemption practice has "a clean break from the McCarran-Ferguson factors", two requirements instead of three requirements, directed at insurance and affected risk pool, instead of insurance policy;

 

3. From footnote 1, These state any willing provider statutes, external review statutes and utilization review statutes are not preempted by ERISA, and applicable to non-insuring HMO, non-insuring TPA's providing administrative service to self-funded ERISA plans. This ruling answered questions unanswered from Rush Prudential HMO, Inc. v. Moran for Texas Independent Medical Review Statutes, as to whether such state independent medical review statutes are applicable to self-insured ERISA plans.

 
'Any Willing Provider' Decision by Supreme Court Might Be More Than Meets the Eye (Managed Care Magazine)
 

Supreme Court's New Savings Clause Test Means More Indirect State Regulation of Self-Funded Plans (Thompson Publishing Group)

 

Supreme Court Articulates New Test for Determining Whether State Laws Regulate Insurance for ERISA Preemption Purposes [Kentucky Ass'n of Health Plans, Inc. v. Miller, 2003 U.S. LEXIS 2710 (U.S. 2003)]--(EBIA)
 

High Court Ruling Gives HMO Patients More Choices WASHINGTON (Reuters)

 

Excerpt:  "WASHINGTON (Reuters) - A unanimous U.S. Supreme Court on Wednesday upheld state laws that require health maintenance organizations to open up their networks and give patients more choices of doctors or other medical providers.

 

The high court upheld two Kentucky laws that HMOs contract with any doctor or chiropractor in the region who agrees to abide by the plan's rules. About half of the nation's 50 states have such "any willing provider" laws."

 

 

Commentary: High Court Punches Another Hole in the Federal Law Shielding HMOs (American Medical News)

 

 Federal court dissolves 'any will provider' injunction  (Arkansas News Bureau)
 

RUSH PRUDENTIAL HMO, INC. v. MORAN [00-1021]

U.S. Supreme Court, Decided June 20, 2002

  00-1021. Rush Prudential HMO, Inc. v. Moran 01/16/02

 

 

SUPREME COURT ALLOWS ILLINOIS STATUTE REQUIRING HMO TO PROVIDE INDEPENDENT MEDICAL REVIEW ON DEMAND

Excerpt (from unofficial syllabus): 'The Illinois HMO Act is directed toward the insurance industry, and thus is an insurance regulation   under a commonsense view.... Congress recognized, the year before passing ERISA, that HMOs are risk-bearing organizations subject to state insurance regulation. That conception has not changed ..." (U.S. Supreme Court)
 

Supreme Court's Preemption Rollback Hangs Over Employer Health Plans, Managed Care Organizations (PDF) (Gardner Carton & Douglas)

 

Excerpt: "[Rush Prudential HMO, Inc. v.] Moran continues a string of decisions, begun by the [Supreme] Court in 1995, which narrow the 'ERISA preemption' doctrine that once seemed to put a stranglehold on states' ability to regulate healthcare. Moran may turn out to be the most significant of all these decisions, through applications of its analysis to other preemption issues."

 

ERISA 'Root Bound' in the States' Garden:

Highlights of Rush Prudential HMO, Inc. v. Moran (pdf)

Health Plan & Provider Report, By BNC, Inc

 

AAHP Statement on Supreme Court Ruling in Rush Prudential HMO, Inc. v. Moran and State of Illinois (6/20/2002)
 
Press Release - Boehner, Johnson Respond to Supreme Court Health Care Decision
 

 

Montemayor v. Corporate Health Ins.(U.S. 2002)
 

Supreme Court Orders 5th Cir. to Reconsider Its Decision on Texas "Independent Review" Statute (EBIA Weekly)

 

Excerpt: "In the [Rush Prudential HMO v. Moran] decision, the [U.S. Supreme] Court rejected the analysis of the Fifth Circuit, which had found a similar independent review law in Texas to be preempted because it conflicted with ERISA's civil enforcement provisions. The Supreme Court has now vacated the judgment in the Fifth Circuit case and sent the case back for further consideration in light of the Rush opinion."
 

Pennsylvania Supreme Court finds that State Law Claims Against Plan Decision-Makers for (Groom Law Group)

 

Egelhoff v. Egelhoff

 

"certiorari to the supreme court of washington

 

No. 99-1529. Argued November 8, 2000--Decided March 21, 2001

 

While David A. Egelhoff was married to petitioner, he designated her as the beneficiary of a life insurance policy and pension plan provided by his employer and governed by the Employee Retirement Income Security Act of 1974 (ERISA). Shortly after petitioner and Mr. Egelhoff divorced, Mr. Egelhoff died intestate. Respondents, Mr. Egelhoff's children by a previous marriage, filed separate suits against petitioner in state court to recover the insurance proceeds and pension plan benefits. They relied on a Washington statute that provides that the designation of a spouse as the beneficiary of a nonprobate asset--defined to include a life insurance policy or employee benefit plan--is revoked automatically upon divorce. Respondents argued that in the absence of a qualified named beneficiary, the proceeds would pass to them as Mr. Egelhoff's statutory heirs under state law. The trial courts concluded that both the insurance policy and the pension plan should be administered in accordance with ERISA, and granted petitioner summary judgment in both cases. The Washington Court of Appeals consolidated the cases and reversed, concluding that the statute was not pre-empted by ERISA. The State Supreme Court affirmed, holding that the statute, although applicable to employee benefit plans, does not "refe[r] to" or have a "connection with" an ERISA plan that would compel pre-emption under that statute."

 

 

PEGRAM et al. v. HERDRICH
U.S. Supreme Court, 06/12/2000

 

ERISAclaim.com Comment:  Most Important ERISA Ruling for health-care providers, yet poorly understood.

1."Held: Because mixed treatment and eligibility decisions by HMO physicians are not fiduciary decisions under ERISA,...."

    Only pure eligibility/coverage decisions are ERISA business, mixed treatment/medical necessity and/then eligibility/coverage exclusion/denial are not ERISA business, not preempted by ERISA;

2. "(b) Under ERISA, a fiduciary is someone acting in the capacity of manager, administrator, or financial adviser to a "plan,"....Thus, in every case charging breach of ERISA fiduciary duty, the threshold question is not whether the actions of some person providing services under the plan adversely affected a beneficiary's interest, but whether that person was performing a fiduciary function when taking the action subject to complaint."

     Performing medical necessity evaluation and making initial denial are not fiduciary functions, making denial decisions on appeals and interpreting plan coverage provisions are fiduciary functions, thus liable for fiduciary breach;

3.  "...it could be argued that Carle is a fiduciary insofar as it has discretionary authority to administer the plan, and so it is obligated to disclose characteristics of the plan and of those who provide services to the plan, if that information affects beneficiaries' material interests."

     On the most complicated but Alzheimer's ERISA land, whoever is making denial decision on appeals and making coverage interpretations (discretionary decision) is a fiduciary, and is obligated to disclose any secret and confidential documents used in claim denials and those who performed medical necessity reviews, if the patient's claims have been denied.

     More discussions can be found on ERISA For Physicians

 

 

GREAT-WEST LIFE & ANNUITY INS. CO. v. KNUDSON [99-1786]  U.S. Supreme Court, 01/08/2002   

                          
"Section 502(a)(3) of ERISA does not allow an employee health plan to seek to impose personal contractual liability on a plan beneficiary under the plan's reimbursement provision, because such relief is legal rather than equitable...."

 
Analysis: Supreme Court Rules Plan Cannot Sue for $400,000 as Reimbursement Despite Plan Language (EBIA Weekly)
 
Trial Court Rejects ERISA Reimbursement Claim, Following Supreme Court's Great-West Decision (EBIA Weekly)

Primax Recoveries, Inc. v. Sevilla (N.D. Ill. 2002). Excerpt: "EBIA Comment: This case illustrates how slippery the constructive trust remedy can be, since it depends so heavily on exactly who is holding the disputed amounts at the time a reimbursement claim is made."

Supreme Court Rules That ERISA Did Not Authorize Insurer's Suit To Enforce Subrogation Provision (Spencernet)
 

Supreme Court Ruling Bars Federal Lawsuits to Achieve Third-Party Recoveries (Thompson Publishing Group)

 
In Great West Decision, Supreme Court Gives Teeth to Its Mertens Decision (McCalla Thompson)
 
Supreme Court Collection home

Supreme Court ERISA Watch Ends

 

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

 

ERISA
Medical Killing
ERISA
Medical Inflation
ERISA
Insurance Robbery

Read Making a Killing

?

 

?

Bar graph showing trends in hospital charges and revenues in California from 1995-2002

?

 

?

GAO-04-312

?
 

?

American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

One Nation under Debt: U..S. economy threatened by aging of America

 

Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)

 

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

 

 

 

U.S. Health-care Crisis & ERISA Criminal Enforcement

 

Aetna + CIGNA Settlement
Demystified

 © 2004  Jin Zhou, ERISAclaim.com

 

Settlements = ERISA + 3 E. B.

(Click on each hyperlinks for details)

 

"Aetna and CIGNA Settlement Secrets"

"Talking Points"

 

  1. ERISA stands for Employee Retirement Income Security Act

  2. E. B. = External Boards (of Reviews) (§7.10-7.11): 1) Medical Necessity, 2) Billing & Coding and 3) Policy Coverage

  3. Settlements Only for MCO/Provider Contract Disputes

  4. Settlements Not for Patient Coverage/ERISA Disputes, (§7.10-7.11)

  5. Patient Disputes = ERISA/Coverage/Medical Necessity/Bundling & Down Coding

  6. Provider Disputes = PPO Discount/HMO Capitation/Provider Relationship (DOL FAQ A8)

  7. Patient Disputes Provider Disputes, (DOL FAQ A8); Provider/MCO Contract (PPO/HMO) Disputes are not Triggered until Patient ERISA Disputes With the ERISA Plan Are 100% Resolved or Moot (DOL FAQ C12) (PASCACK VALLEY HOSPITAL, INC. v  LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN (3rd Cir. 11/01/2004)

  8. External Reviews (3 E. B.) Are Not Available until Internal Reviews (ERISA) Completed, (GAO)

  9. ERISA = Federal Law Mandate; External  Reviews = State Law Mandate, (GAO)

  10. No ERISA Compliance = No Rights for Any One

 

 

 

A New Diagnosis & Solution:
EFS-- ERISA FAILURE SYNDROME--Fatality: 31 YOA
 

ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings!

HMO Crisis Is Really An ERISA Crisis!

HMO & PPO Managed Care Contracting to 
Disregard & Substitute
ERISA SPD & Claims Procedure
Is The Primary & Inevitable Cause of Medical Inflation

Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!

 

ERISA Failure Damages Are Greater Than
9/11 and Pearl Harbor Tragedies Combined

U.S. Health-care Crisis & ERISA Criminal Enforcement

 

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right"- "John Q. ERISA Enforcement".

United States Department of Health and Human Services: Leading America to Better Health, Safety and Well-Being
 

2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

HHS FAQ "Questions On Charges For The Uninsured" (PDF)

HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

 

OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"

 

 

Press Release      Complaint (pdf)

 

U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT

"January 5, 2004 - PHILADELPHIA – United States Attorney Patrick L. Meehan announced today the filing of the Government's complaint against national accounting firm Ernst & Young. According to the complaint, nine hospitals paid Ernst & Young for billing advice – advice which later caused the submission of false claims to the Medicare program."

.....

"It is the responsibility of an independent reviewer to be alert to fraud and abuse and certainly not to ignore it," said Meehan. "In this case, as the complaint alleges, Ernst & Young kept itself deliberately ignorant of the facts."

Labor Department Sues Corporation For Violating Federal Employee Benefit Law (Release Date: 02/02/2004)

"Columbus, Ohio - The U.S. Department of Labor has sued defunct General Clay Products Corporation, of Columbus, Ohio, for abandoning the company’s retirement plan, and also filed suit against its president for failing to forward employee contributions to the health plan. The alleged violations resulted in the loss of health insurance coverage for company workers."

‘‘Medicare Prescription Drug, Improvement, and Modernization Act of 2003’’ (pdf) (415) (A full text of the H.R. 1)

JS-1061: Treasury Issues Guidance To Encourage Use Of New Innovative Health Savings Accounts ("HSAs")

Text of IRS Notice 2004-2: Guidance on Health Savings Accounts (PDF) (Internal Revenue Service)

13 pages. Excerpt: "This notice provides certain basic information about HSAs in question and answer format, without attempting to enumerate all of the specific rules that apply under section 223. The notice is divided into five parts. Part I of the notice explains what HSAs are and who can have them. Part II describes how HSAs can be established. Parts III and IV cover contributions to HSAs and distributions from HSAs. Part V discusses other matters relating to HSAs."

Overview of Health Savings Accounts With Chart Comparison to Archer MSAs, HRAs and FSAs (PDF) (Miller & Chevalier Chartered)

 

How Health Savings Accounts Compare To FSAs and HRAs (Groom Law Group)

 

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

 

"Zhou's Model of Prudent Health Care"

Are All Consultants Corrupt? (Fast Company)

    The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings:

  1. ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions;

  2. ERISA Compliant Claims Procedure as the Only Rule for Every One;

  3. Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity"

(GM Current Model: $5.1 billion/yr, $1,400/vehicle)
(GM says health care obligation hit $67.5 billion in 2003)

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

General Motors National Benefit Center

Health Spending Projections Through 2013

New Federal Claim Regulation (Final Rule)
Benefit Claims Procedure Regulation (FAQ)
Amendments to Summary Plan Description Regulations
(Final Rule)
Patient's Rights Claims Procedure Regulation (Fact Sheet)

U.S. Health-care Crisis & ERISA Criminal Enforcement

CBO's analysis of the President's budgetary proposals for fiscal year 2005

Fact Sheet: Affordable Health Care for America's Families (White House)

 

 

DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf)
Compliance Assistance for Group Health Plans (Top 15 Tips)

950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna and CIGNA Settlement Secrets"
ERISA Certification Programs for Maximal Reimbursement

What You Should Know about Filing Your Health Benefits Claim
HIPAA Nondiscrimination Requirements Frequently Asked Questions

 


U.S. Health-care Crisis
& ERISA Criminal Enforcement



ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits

 

ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's

 

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

ERISAclaim.com:  ERISA Certification Programs
for Cost-Saving & Reimbursement by Compliance

 

ERISAclaim.com - U.S. Health-care Crisis
& ERISA Criminal Enforcement

 

 

DOL + DOJ Enforcement of ERISA

 

    

 

HHS Works with ERISA (+77 Millions/4 Yrs)

 

 

 

DOL Compliance Assistance for Health Plans

 

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

ERISA in US CODE

 

 

New HIPAA Privacy and ERISA Claims Review Rules: 10 Reasons To Comply (Brown Rudnick Berlack Israels L.L.P.)
 

Group Health Plan Compliance with ERISA and HIPAA: Navigating the Legal and Administrative Maze (PDF) (Brown Rudnick Berlack Israels L.L.P.)

72 pages. A 'Question and Answer Resource Guide."

 

DOL

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

 

Fact Sheet - What To Do If Your Health Coverage Can No Longer Pay Benefits

 

Questions and Answers: Recent Changes in Health Care Law (PDF)

 

Continuation of Health Coverage – COBRA

 

HIPAA Nondiscrimination Requirements Frequently Asked Questions

 

 

HHS Press Release:
 

2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

HHS FAQ "Questions On Charges For The Uninsured" (PDF)

HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

 

OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"



National Correct Coding Initiative Edits - Version 11
 

National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.3


2003 Improper Medicare Fee-for-Service Payments Report

 

CMS Announces Revisions to Payment for Drugs and Physician Fee Schedule Payments for Calendar Year 2004

 

Medicare Announces 2004 Physician Fee Schedule and Payment Policy Changes

CMS Files for Download for Medicare Payment Systems

 

CMS Finalizes Appeals Process for Medicare Coverage Decisions

 

2003.12.10: HHS Announces Immediate Steps to Make Medicare-Approved Drug Discount Card Programs Available Next Spring

 

42 CFR Parts 403 and 408
Medicare Program; Medicare Prescription
Drug Discount Card; Interim Rule and Notice (pdf) (89 pages)

 

Revision of Billing Instructions for Purchased Services
 

Regional Offices Link


2004 Medicare Payment Information Available from CD-Rom (WPS, WI,MI,IL, MN)

 

HIPPA Final

 

AMNews through  AMA

Health plans subject to new federal appeals rules
Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.

 

ERISA Not Insurance

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

Aetna Reaches Agreement with Physicians, May 22, 2003 (Aetna.com)

 

 

Managed Care and Patients' Rights
(JAMA Editorial)

 

$10,600 ERISA Claim

Recent Federal Court Ruling in a Case with $10,600 medical claim, insurance Co. refused to pay, provider made numerous demand for payment in almost one year, but no appeals filed, the court dismissed the lawsuit because provider failed to exhaust administrative remedy, as required under ERISA, by filing ERISA claim appeals.  This situation is so popular in health-care community.

 

 

$37,350 ERISA Claim

Health-care provider alleged medical claims submitted to Aetna for reimbursement, Aetna asserted no receipt of medical claims, no written denials.  Health-care provider failed to present proof of claim submission, claim denial and ERISA claim appeals. This case was dismissed. ERISA health-care claims are handled in federal court, state law is generally not applicable.

 

 

 

PACIFIC COAST HOSPITAL v. AETNA HEALTHCARE

"requesting payment of benefits and/or to discuss the matter in further detail" by hospitals are wasting time and money

 

 

One Employee, One Shareholder, But ERISA Plan

(Name of the Game for 80 Percent of Health-care Claims in U.S.)

Gilbert v. Alta Health & Life Insurance Co. (11th Cir. No. 01-10829,12/27/01).

 

NHPF Publications  

 

NHPF Publications  

 

NHPF Publications  

 

 

2002 Employee Health Benefits Survey (Kaiser Family Foundation)

 

Survey: Employee Benefits in Private Industry (2000) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

 

Are more workers covered by traditional fee-for-service plans, HMOs, or PPOs?

 

Definitions of Health Insurance Plans and Other Terms (Federal Government’s Interdepartmental Committee)

 

 

 

 

DOL Secretary Testifies to Committee About ERISA Enforcement, Compliance Assistance (U.S. Department of Labor, Pension and Welfare Benefits Administration)

 

 

Study: Health Insurance Premiums Rose More Than 30 Percent Between 1996 and 2000 (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality)

 

 

 

 

 

 

Opinion: Cutting Costs in Half Through Better Management is Fantasy But Health Care Debate Is Real (The Hartford Courant)
Excerpt: "If a talk on economics can have a $650 billion throwaway line, Treasury Secretary Paul O'Neill delivered it.... "

 

"O'Neill insists the problem is not with people, but systems - systems that invite medical errors, systems that penalize health care professionals for making honest mistakes, systems that create the mind-numbing complexity of reimbursement for providers, systems that reward too much treatment and punish efficiency."

 

ctnow.com

 Health Cost Trends Shift

"The study said managed care probably has squeezed out all the savings it can from the nation's health care system and that employers are turning to other familiar devices such as increasing premiums and co-payments to trim their costs"

 

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

 

Health Care Issues Stymie Congress (The Hartford Courant)

 

 

 

 

 

 

Kinder and Gentler: Physicians and Managed Care, 1997-2001 (Center for Studying Health System Change)

 

 

 

 

 

 

Employer Spending on Health Care: 1987-2000 (Employee Benefit Research Institute)

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

 

Health Care Spending Rose 8.7% in 2001, the Fastest Rate in 10 Years, Government Statistics Say

 

In Largest Increase in 12 Years, Health Care Spending Rose 7% in 2000 ...

 (KaiserNetwork.org)

 

 

Employer Health Benefits: 2002 Annual Survey.(pdf)
Accessibility verified January 30, 2003
(KaiserNetwork.org)

 

 

National Compensation Survey: Employee Benefits in Private Industry in the United States, 2000 (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

 

 

Data Provide Details on Characteristics of Health Insurance of U.S. Workers (Agency for Healthcare Research and Quality)

 

 

GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

"What GAO Recommends:

The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

modifications and make them publicly available."

 

 

 

 

   
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