Our blog series on best practices in administering benefit claims has thus far stressed the importance of knowing and reading the plan document and summary plan description. This week, we take a look at a plan term that has been the subject of frequent dispute in health and welfare benefits claim litigation—interpretation of plan provisions
Assignments
Third Circuit Upholds Health Plan’s Anti-Assignment Clause
By Russell Hirschhorn on
The Third Circuit recently held that anti-assignment clauses in ERISA-governed healthcare plans are enforceable as long as they are unambiguous. The Court concluded that the anti-assignment clause clearly stated that participants could not assign their rights under the plan; and the plan’s statement that payments made directly to a provider did not transfer to that…
Out-of-Network Physician’s Claim Against Insurer Not Preempted by ERISA
By Lindsey Chopin on
The Second Circuit concluded that a promissory estoppel claim by an out-of-network provider against an insurer was not completely preempted by ERISA and thus remanded the claim to state court for further proceedings. The provider’s claim was predicated on its assertion that the insurer made certain representations about coverage for the insured. The Court held…
Valid Assignment Confers Beneficiary Status on Chiropractor
By Todd Mobley on
A federal district court in Illinois recently issued a pair of rulings in cases where insurers sought to recoup payments from practitioners. Pennsylvania Chiropractic Association v. Blue Cross Blue Shield Association, 2013 U.S. Dist. LEXIS 159331 (N.D. Ill. Nov. 7, 2013); 2013 U.S. Dist. LEXIS 159491 (N.D. Ill. Nov. 7, 2013). Plaintiffs, three individual…
Chiropractors Lack Standing Under ERISA to Assert Claims For Benefits
By Aaron Feuer on
A federal district court in New Jersey recently dismissed claims asserted by a putative class of chiropractors seeking to enjoin the procedure used by UnitedHealth to determine the necessity of certain treatments administered by in-network physicians, finding that they lacked standing to assert their claims. Premier Health Ctr., P.C. v. UnitedHealth Grp., No. 2:11-cv-00425-ES-CLW…