California recently enacted Senate Bill 855 (?Ç£SB 855?Ç¥), which expands certain requirements related to mental health and substance use disorders. SB 855 applies to any California ?Ç£health care service plan contract?Ç¥ or disability insurance policy issued, amended, or renewed on or after January 1, 2021. Significantly, SB 855 renders ?Ç£void and unenforceable?Ç¥ any provision in a health care service plan contract that reserves discretionary authority to the plan to determine eligibility for benefits or coverage, interpret the terms of the contract, or provide for standards of interpretation or review that are inconsistent with California law. If this provision is not preempted by ERISA as applied to an employer-sponsored group health plan, such mandate could eliminate the deferential standard of review that would otherwise be available under ERISA to the plan administrator. SB 855 is available here.
Fifth Circuit Defers to Plan Administrator?ÇÖs Claim Appeal Decision Involving Competing Medical Opinions
In Rittinger v. Health Alliance Life Insurance Company, the U.S. Court of Appeals for the Fifth Circuit, whose jurisdiction includes Texas, analyzed the claims decision-making process of a group health plan administrator that had been granted discretion under the terms of the employer?ÇÖs group health plan. The court determined that, based on such grant of discretion, the plan administrator?ÇÖs decision regarding a participant?ÇÖs benefits claim appeal was entitled to judicial deference, even with respect to the plan administrator?ÇÖs selection of competing medical providers?ÇÖ opinions. Background regarding Grant of Discretion under ERISA Under general standards, a court will consider denials of appealed benefits claims under an employer-sponsored employee benefit plan (including a group health plan) that is subject to ERISA on a ?Ç£de novo?Ç¥ basis, which means that the court will not give any deference to the plan administrator?ÇÖs prior decision on a benefit claim appeal, but instead can substitute its… Continue Reading