[firm] blog logo

Inaccurate Leave of Absence Provisions May Lead to Stop Loss Carrier Denial of Claims

For employees on a leave of absence (?Ç£LOA?Ç¥) or a furlough, employers often extend group health plan coverage during the LOA or furlough for a prescribed time period. With regard to group health plans that are considered to be ?Ç£self-insured,?Ç¥ generally, the employer?ÇÖs reinsurer, or stop loss carrier, is only required to cover claims (above the policy?ÇÖs self-insured retention level) incurred for a covered person based on the written terms of the plan. In other words, the policy underwrites the coverage that is provided under the plan document. If extended coverage during a LOA or furlough is not expressly set out in the plan document, a stop loss carrier could seek to deny claims incurred during that period. It is thus recommended that employers with self-insured plans review their health plan documents to ensure consistency with administrative practices regarding coverage during LOAs and furloughs and coordinate as necessary with the… Continue Reading

Regulations Provide for More Cost Transparency in Health Coverage

The federal Departments of Health and Human Services, Labor, and the Treasury (collectively, the ?Ç£Departments?Ç¥) have jointly issued final regulations that are intended to provide for more transparency in health coverage (the ?Ç£Regulations?Ç¥). The Regulations have important implications for employer sponsors of certain group health plans (?Ç£Plans?Ç¥) and health insurers. The Regulations do not apply to health plans that are grandfathered under the Affordable Care Act, health reimbursement arrangements, certain other account-based group health plans, or short-term limited duration insurance. The Regulations require two key forms of disclosures (collectively, the ?Ç£Disclosures?Ç¥) in order to provide for this improved transparency: Self-Service Disclosure. First, the Regulations require Plans and insurers in the individual and group markets to disclose certain cost-sharing information upon request to a participant, beneficiary, or enrollee (or his or her authorized representative), including (a) an estimate of the individual?ÇÖs cost-sharing liability for covered items or services furnished by a… Continue Reading

Delegating Fiduciary Duties Under ERISA Plans

The recent decision in Hampton v. National Union by the U.S. District Court for the Northern District of Illinois highlights the importance of following the provisions in ERISA plan documents for delegating fiduciary duties to entities acting as plan fiduciaries, such as third-party service providers and insurers. Following the death of her husband, who was an employee of The Boeing Company (?Ç£Boeing?Ç¥), the plaintiff sought to recover accidental death and dismemberment benefits under insurance policies sponsored by Boeing, for which she was the sole designated beneficiary. After National Union, which underwrote and co-administered the policies with AIG Claims, Inc., denied the plaintiff?ÇÖs initial benefits claim, as well as her appeal of such denial, the plaintiff brought suit under ERISA. The plaintiff argued that the court should apply a de novo standard of review (i.e., no deference given to the plan fiduciary?ÇÖs prior decisions) because National Union did not have discretionary… Continue Reading

Cross-Plan Offsetting Practice is Challenged in Class Action Lawsuit

This class action lawsuit, styled Scott, et al. v. UnitedHealth Group, Inc., et al., was filed in the U.S. District Court for the District of Minnesota on July 14, 2020. This lawsuit follows the decision of the U.S. Court of Appeals for the Eighth Circuit in Peterson v. UnitedHealth Group Inc. that was issued last year. In Scott, the plaintiffs, who were participants in the plans at issue in Peterson, filed, on behalf of a class of plaintiffs (the ?Ç£Class?Ç¥), a class action against UnitedHealth Group, Inc. and its wholly-owned subsidiaries (collectively, ?Ç£UHC?Ç¥), in their capacities as an insurer and/or third-party claims administrator of employer-sponsored group health plans. The lawsuit alleges the breach of UHC?ÇÖs fiduciary duties under ERISA as related to UHC?ÇÖs practice of ?Ç£cross-plan offsetting.?Ç¥ The Class consists of participants and beneficiaries in all group health plans that are administered by UHC and contain ?Ç£cross-plan offsetting?Ç¥ (collectively, the… Continue Reading

Bostock v. Clayton County, Georgia ?Çô What It May Mean for Group Health Plans

The U.S. Supreme Court?ÇÖs recent decision in Bostock v. Clayton County, Georgia held that Title VII of the Civil Rights Act of 1964 protects the employment rights of individuals who are gay, lesbian, or transgender because ?Ç£sex plays a necessary and undisguisable role?Ç¥ in discrimination based on sexual orientation and gender identity. Although this case addressed whether an employer could fire an individual based on sexual orientation or gender identity, there could also be important implications for benefit plans. For example, employees could use the Bostock decision to seek coverage under group health plans for certain procedures that have traditionally been excluded from coverage, such as gender-affirmation surgery, arguing that such exclusions violate the protections under Title VII. If the plan covers implants after a mastectomy but would not cover the same procedure for an individual who is transitioning, the exclusion for transitioning individuals may also be challenged based on… Continue Reading

Top Five Tips for Maximizing Insurance Claims in a Hard Insurance Market

When the book is closed on 2019, it will be remembered by many risk managers as the ?Ç£hardest?Ç¥ insurance market in years. While the effects of a hardening market have been more pronounced in some sectors and magnified for specific coverages, policyholders across the board have experienced increases in premiums, reduced capacity, and more restrictive terms in all lines. These adverse market conditions have appropriately prompted many insureds to develop new strategies for renewals in 2019 and in the year ahead. Equal attention should be paid to the pursuit of outstanding claims. Effective claims management can not only increase recovery for the policyholder in the short run but may also influence future underwriting and the impact of continued hardening in markets over the coming year. Here are five tips for policyholders to increase recovery of claims in the current hard insurance market. Provide Timely Notice Of Claims & Continue To… Continue Reading

4th Annual Texas Insurance Academy

Registration now open! Insurance professionals and counsel are invited to attend our 4th Annual Texas Insurance Academy Conference on October 24, 2019, at the Haynes and Boone office in Dallas, Texas. Attendees can expect to learn from risk managers, coverage counsel and brokers about important insurance issues affecting businesses from a broad range of industries. Our experienced panels will share their knowledge on how to navigate through a hard market, including: ?Çó State of Play: Hardening Insurance Markets ?Çó Factors Driving the Hardening Market ?Çó Top 10 ?Ç£Don?ÇÖts?Ç¥ When Negotiating Your Policy ?Çó Important Developments in Texas Insurance Law ?Çó Strategies for Dealing with the Hardening Market ?Çó A Look at Future Risks Date: Thursday, October 24, 2019Time: 7:45 a.m. ?Çô 4:30 p.m.Location: Haynes and Boone, LLP, 2323 Victory Avenue, Suite 700, Dallas, TX 75219 Register HereAgenda For more event information please email Patricia Kirven. About the Texas Insurance Academy: The… Continue Reading

Texas Supreme Court Provides Guidance On The Recoverability Of Judgments Entered Against An Insured By Third-Party Plaintiffs

In a much anticipated decision, the Texas Supreme Court has given direction to policyholders and third-party plaintiffs on the circumstances under which a judgment entered against the policyholder will be recoverable from the judgment debtor?ÇÖs insurer.?á The case is important to insureds defending against third-party claims because it offers instruction on how to transfer liability appropriately to an insurer for an adverse judgment.?á The decision is equally important to plaintiffs seeking to maximize recovery of judgments against parties, whose greatest asset may be a liability policy. In Great American Insurance Company v. Hamel, 2017 WL 2623067 (Tex. June 16, 2017), homeowners obtained a judgment against a builder for defective workmanship in a bench trial held after the homeowners agreed with the builder not to pursue the builder?ÇÖs owner or the owner?ÇÖs personal assets in satisfaction of a judgment entered against the builder.?á After trial, the builder assigned all claims against… Continue Reading

Federal District Court in Texas Rules on Cigna?ÇÖs ?Ç£Fee Forgiveness?Ç¥ Protocol in the Administration of Medical Benefit Claims

The U.S. District Court for the Southern District of Texas recently ruled on motions for summary judgment by both parties in North Cypress Medical Center Operating Company, Ltd v. Cigna Healthcare, holding that Cigna?ÇÖs application of its ?Ç£fee forgiveness?Ç¥ protocol (the ?Ç£Protocol?Ç¥) in the administration of benefit claims for medical services rendered by North Cypress was legally incorrect and constituted an ?Ç£abuse of discretion?Ç¥ under ERISA. ?áCigna performed claims administration services as a third-party service provider for employer-sponsored, self-funded group medical plans and as the insurer under employer-sponsored, fully-insured group medical plans (collectively, the ?Ç£Plans?Ç¥). ?áNorth Cypress was an out-of-network healthcare services provider (an ?Ç£OON Provider?Ç¥) that offered to waive or discount patients?ÇÖ cost-sharing obligations in exchange for prompt payment for its billed services. ?áWhen North Cypress submitted the patients?ÇÖ benefit claims to Cigna, Cigna applied the Protocol, which significantly reduced or denied the claim payments to North Cypress based… Continue Reading

Is Your ERISA Fiduciary Liability Insurance Up to Date?

ERISA fiduciary liability insurance policies protect fiduciaries and trustees of ERISA plans from personal liability. As fiduciary liability law changes, it is important to make sure that such policies cover the appropriate risks and to evaluate whether the coverages are sufficient and complete. Newer and more comprehensive policies not only cover breaches of fiduciary duty and administrative errors, but settlor and non-fiduciary functions and regulatory penalties as well. Companies should evaluate their policies and consider, depending on their needs, whether the following items are covered and/or should be covered under their policies: Coverage for costs and expenses of DOL and other regulatory audits/investigations. Coverage for claims involving settlor/non-fiduciary functions. Coverage for failures to comply with certain ERISA disclosure requirements. Coverage for ERISA 502(a)(3) equitable-relief claims. Coverage for non-exempt prohibited transactions under ERISA and the Internal Revenue Code. Coverage for plan benefit overpayments. Coverage to pay for costs involved in corrections… Continue Reading

October 2021
S M T W T F S
 12
3456789
10111213141516
17181920212223
24252627282930
31  

Archives