This summary of key lawsuits affecting managed care is provided by the Health Care Law Group of Crowell & Moring LLP. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group.

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To search the entire archive of cases, hit 'Control F' and type your desired search phrase.

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September 2017 Managed Care Lawsuit Watch [full version]

• U.S. Supreme Court held that Kentucky’s clear-statement rule requiring that powers of attorney by nursing home residents expressly include the power to execute arbitration agreements on their behalf violated the Federal Arbitration Act
  The U.S. Supreme Court held that a Kentucky Supreme Court’s decision requiring a nursing home resident’s power of attorney document to expressly include arbitration agreements in their grant of authority violated the Federal Arbitration Act by singling out arbitration agreements for disfavored treatment.
  
  Two relatives of deceased nursing home patients who held powers of attorney sued Kindred Nursing Centers on behalf of their deceased relatives’ estates alleging that Kindred’s substandard care resulted in their deaths. Kindred filed a motion to dismiss arguing that it had a binding arbitration agreement with the plaintiffs, but the Kentucky Supreme Court held that state law required that the power of attorney documents expressly include a clause granting authority to enter into arbitration agreements. The U.S. Supreme Court held that this violated the FAA.
  
  The Supreme Court held that the Kentucky rule violated the equal-treatment principle, which prohibits courts from imposing restrictions specifically on arbitration agreements that do not apply to other types of contracts, because it imposed an additional obstacle for enforcing an arbitration agreement. The Supreme Court also held that the FAA applies not only to the validity of an arbitration agreement but also to its formation. Thus, the state court’s rule imposing an additional barrier to entering into a valid arbitration agreement could not stand as it was inconsistent with the FAA.
  Kindred Nursing Centers L.P. v. Clark
  
  
• Second Circuit holds that ERISA does not completely preempt an out-of-network provider’s state-law claim
  The United States Court of Appeals for the Second Circuit held that ERISA does not completely preempt an out-of-network provider’s state law promissory estoppel claim against a health insurer because the provider (1) did not receive a valid assignment for payment under the health care plan and (2) received an independent promise from the insurer that he would be paid for certain medical services.
  McCulloch Orthopaedic Surgical Servs. PLLC v. Aetna Inc., et al.
  
  
• Substance abuse provider was not an emergency services provider for purposes of the California Knox-Keene Act’s claims reimbursement regulations
  The California Court of Appeal for the Fourth District affirmed a dismissal of a complaint against a health plan holding that it was not obligated to pay a substance abuse provider the “usual, reasonable and customary” rate for its services when it was not an emergency services provider and there was no contractual agreement to do so.
  
  The Court of Appeal reasoned that under the applicable California law, non-contracted physicians providing nonemergency services are reimbursed at the rate set forth in the health plan member’s evidence of coverage (EOC), and not at the “the usual, reasonable and customary” rate. The court rejected the idea that the substance abuse provider was an emergency services provider based on the inability of most of its patients to examine the marketplace and select a certain provider. Since the non-contracted substance abuse provider did not allege that it provided emergency services to the plan member, the panel held that its right to reimbursement was under the plan member’s EOC and not based on the market value of the services.
  Pacific Bay Recovery, Inc. v. Cal. Physicians’ Servs., Inc.
  
  
• California Court of Appeal holds that trial court properly considered fees charged by other providers and Medicare rates to determine the “usual, reasonable and customary” value of emergency services
  The California Court of Appeal affirmed the trial court’s judgement that the fees paid by Regal Medical Group, Inc. to Sanjiv Goel, M.D., Inc. were the “usual, reasonable and customary” value.
  
  The Court addressed the type of evidence the trial court considered when determining Goel’s quantum meruit claim. Consistent with Children's Hosp. Cent. California v. Blue Cross of California, 226 Cal. App. 4th 1260 (2014), the Court of Appeal reasoned it was proper for the trial court to consider a range of factors, including other providers’ rates and Medicare rates, to calculate the “usual, reasonable and customary” value of rendered emergency services. But, the Court noted that Medicare rates may offer little to no weight, depending on the facts of the case. As such, the Court of Appeal ultimately affirmed the lower court’s ruling, finding no error in the evidence the trial court considered to determine the “usual, reasonable and customary” value of Goel’s rendered services.
  Sanjiv Goel M.D., Inc. v. Regal Med. Grp., Inc.
  
  
• The U.S. District Court for the Southern District of Florida denies motion for summary judgment on a relator’s claim that the health plan falsified Medicare risk adjustment data
  The U.S. District Court for the Southern District of Florida denied Humana, Inc.’s motion for summary judgment on the relator’s claims under the False Claims Act. Although Graves did not identify specific instances in which Humana improperly billed Medicare, the Court found that evidence in the record raised genuine issues of material fact as to whether Humana’s submissions of risk adjustment data to the Centers for Medicare and Medicaid Services on behalf of its providers, Plaza Medical Centers and Dr. Cavanaugh, rose to the level of reckless disregard under the FCA.
  
  The issue in both of the relator’s claims under the FCA turned on Humana’s knowledge of whether the risk adjustment data it submitted to CMS were false. In denying the motion for summary judgment, the Court found that despite Humana’s implementation of a compliance program and Special Investigations Unit per CMS requirements, the relator alleged sufficient facts to create a genuine issue of material fact as to whether Humana acted with reckless disregard because Humana potentially ignored red flags that should have led it to investigate the validity of the risk adjustment data submitted to CMS. The Court determined that there was a genuine issue as to whether Humana made a good faith effort to create safeguards to avoid submitting false claims. The Court also rejected Humana’s argument that it had made a reasonable interpretation of ambiguous regulations which require MAOs to make “good faith efforts” to certify the accuracy of data submissions and establish an “effective” compliance program. The Court concluded that there was sufficient evidence to support the relator’s claim under the reverse false claims provision of the FCA that Humana had actual knowledge that it received overpayments from Medicare or Medicaid funds which it had not timely returned to the government.
  Graves v. Plaza Medical Centers, Corp.
  
  
• U.S. District Court for the Eastern District of Missouri dismissed pharmacy benefits manager’s counterclaim for fraudulent inducement but held that counterclaims for breach of contract and unjust enrichment could go forward
  When Express Scripts, Inc.—a pharmacy benefits manager—terminated Prime Aid Pharmacy Corp.—a licensed pharmacy that provides retail and specialty medications—from its network, Prime Aid sued ESI in the U.S. District Court for the Eastern District of Missouri claiming breach of contract. ESI alleged three counterclaims, which Prime Aid moved to dismiss. Although ESI’s counterclaim for fraudulent inducement could not survive Prime Aid’s motion to dismiss, the Court held that ESI’s counterclaims for unjust enrichment and breach of contract against Prime Aid could go forward. These counterclaims were based on allegations that Prime Aid failed to reverse claims it sent to ESI and improperly retained monies it was not entitled to keep.
  
  The District Court ruled that ESI’s counterclaim for fraudulent inducement could not survive Prime Aid’s motion to dismiss because ESI failed to plead that Prime Aid acted with the requisite intent. The Court also found that ESI stated a plausible claim for breach of contract and unjust enrichment based on allegations that Prime Aid improperly retained overpayments it received from ESI. The Court, however, noted that ESI could not bring claims based on allegations that Prime Aid merely failed to timely reverse its claims submissions because ESI could not allege any damages for claims that Prime Aid ultimately reversed.
  Prime Aid Pharma. Corp. v. Express Scripts, Inc.
  
  

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February 2017 Managed Care Lawsuit Watch [full version]

• U.S. Court of Appeals affirms dismissal holding that plaintiff asserting actual anticompetitive effects to prove Sherman Act Section 1 violation must show anticompetitive effects on the market as a whole
  
  Deborah Heart & Lung Center v. Virtua Health, Inc.
  
  
• Pennsylvania Supreme Court holds state statute requiring consolidation of wrongful death and survival claims preempted by Federal Arbitration Act
  
  Taylor v. Extendicare Health Facilities, Inc.
  
  
• California Court of Appeal finds ERISA does not preempt medical provider’s contract and quasi-contract claims based on representations about payment for services
  
  Morris B. Silver M.D., Inc. v. Int’l Longshore & Warehouse Union—Pac. Maritime Assoc. Welfare Plan
  
  
• California Appellate Court declares statute of limitations on quantum meruit claims begin to run on date physician receives an explanation of benefits (EOB) from insurer
  
  Vishva Dev, M.D., Inc., v. Blue Shield of California Life & Health Ins. Co.
  
  
• U.S. District Court dismisses remaining claims against insurers accused of using distorted reimbursement rates for out-of-network services
  
  In re WellPoint, Inc. Out-of-Network “UCR” Rates Litigation
  
  

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August 2016 Managed Care Lawsuit Watch [full version]

• Supreme Court holds that ERISA preempts the application of Vermont health data reporting statute to ERISA plans
  
  Gobeille v. Liberty Mut. Ins. Co.
  
  
• Sixth Circuit vacates Blue Cross Blue Shield of Michigan’s antitrust settlement because key documents were filed under seal
  
  Shane Group, Inc. v. Blue Cross Blue Shield of Michigan
  
  
• District Court holds that differing opinions based on clinical judgment or opinion on hospice eligibility alone cannot constitute falsity under the False Claims Act
  
  United States of America v. AseraCare, Inc.
  
  
• California Court of Appeal holds that Kaiser Foundation health plan could not be liable for contracting hospital’s alleged tort under the common law enterprise liability theory
  
  Gopal v. Kaiser Found. Health Plan, Inc.
  
  
• Arizona Court of Appeals holds that OPM subrogation and reimbursement regulations are entitled to Chevron deference and FEHBA preempts Arizona's anti-subrogation law
  
  Kobold v. Aetna Life Ins. Co.
  
  
• New Jersey Appellate Division reverses consolidated discovery orders mandating that an insurer produce confidential and proprietary provider network documents in litigation against certain in-network hospitals
  
  Capital Health Sys., Inc. v. Horizon Healthcare Servs., Inc. and St. Peter’s Univ. Hospital v. Horizon Healthcare Servs., Inc.
  
  

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March 2016 Managed Care Lawsuit Watch [full version]

• Tenth Circuit holds that insurer could seek reimbursement from federal employee health benefit insurance plan member
  
  Helfrich v. Blue Cross & Blue Shield Ass'n
  
  
• California Court of Appeal: utilization management physicians owe duty of care and can be sued for causing new or aggravated injuries that are not the subject of the UM review
  
  King v. CompPartners, Inc.
  
  
• California Court of Appeal finds that independent physician association is not liable for cost of out-of-network laboratory testing services ordered as a result of physician error
  
  Unilab Corp. v. Angeles-IPA
  
  
• The U.S. District Court for the Northern District of California granted summary judgment holding that treating physician’s stabilization determination is binding on Kaiser
  
  Kaiser Found. Health Plan, Inc. v. Burwell
  
  
• Northern District of California denied plaintiffs’ motion to remand the case to the New York Supreme Court in Anthem data breach litigation because plaintiffs’ claims were preempted by ERISA
  
  Smilow and Katz v. Anthem Life & Disability Ins. Co.
  
  
• U.S. District Court holds surgery centers are not health care providers covered under Pennsylvania’s AKS but certifies interlocutory appeal
  
  Aetna Life Ins. Co. v. Huntingdon Valley Surgery Ctr.
  
  
• Southern District of Florida remands contract and sequestration-based reimbursement dispute to state court for lack of subject matter jurisdiction, rejecting health insurers’ claims of removal based on federal officer and federal question grounds
  
  Baptist Hosp. of Miami, Inc. v. Humana Health Ins. Co. of Florida, Inc.
  
  
• District Court in California determines that insured’s claims for invasion of privacy and unfair business practices not preempted by ERISA
  
  Rose v. Healthcomp, Inc.
  
  

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November 2015 Managed Care Lawsuit Watch [full version]

• Third Circuit holds that denial of benefits from ERISA administrator must inform claimants of plan imposed deadlines for civil actions
  Mirza v. Ins. Adm'r of Am., Inc.
  
  
• Pennsylvania District Court dismisses claims alleging that Gilead’s hepatitis C drug pricing violated Section 1557(A) of the ACA and other state laws
  BSE. Pennsylvania Transp. Auth. v. Gilead Sciences, Inc.
  
  
• U.S. District Court denies United States’ motion for reconsideration, allowing bifurcation of FCA elements
  U.S. v. AseraCare, Inc.
  
  
• NY District Court provides first judicial guidance on "identifying" overpayments and effect on FCA liability
  Kane ex rel. United States v. Healthfirst, Inc.
  
  
• U.S. District Court allows Cigna to pursue claims against surgical centers related to fraud and misrepresentation
  Conn. Gen. Life Ins. Co. v. True View Surgery Ctr. One, LP
  
  
• Fixed indemnity insurers: no need to obtain certifications from plan consumers that they have ‘minimum essential coverage’ under the ACA
  Cent. United Life, Inc. v. Burwell
  
  
• Alaska Supreme Court gives green light to Medicaid expansion
  Alaska Legislative Council v. Governor Bill Walker
  
  
• Iowa Supreme Court holds that Wellmark’s agreements do not constitute per se price-fixing
  Mueller v. Wellmark, Inc.
  
  
• Ninth Circuit agrees that merger of two large Idaho PCPs violates Section 7 of the Clayton Act
  St. Alphonsus Med. Ctr.- Nampa Inc. v. St. Luke's Health Sys., Ltd.
  
  

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June 2015 Managed Care Lawsuit Watch [full version]

• U.S. Supreme Court holds that Medicaid providers lack cause of action to challenge state provider reimbursement rates
  Armstrong v. Exceptional Child Ctr, Inc.
  
  
• Ninth Circuit reverses a district court order that a settlement agreement's "no-employment" provision be enforced in an employment discrimination action filed by a physician
  Golden v. Cal. Emergency Physicians Med. Grp.
  
  
• Seventh Circuit affirmed dismissal of plaintiffs' complaint for lack of standing because plaintiffs failed to identify a cognizable injury traceable to the OPM rule that requires Congress to purchase health coverage on exchanges
  Johnson v. U.S. Office of Pers. Mgmt.
  
  
• Sixth Circuit holds that government audit or investigation by itself is not enough to trigger FCA's public-disclosure bar
  U.S. ex. rel. Robert Whipple v. Chattanooga-Hamilton Hosp. Auth.
  
  
• Federal Court in Illinois refuses to dismiss the government's FCA complaint alleging upcoding by a hospitalist physician group practice
  U.S. ex rel. Oughatiyan v. IPC The Hospitalist Co., Inc.
  
  
• District Court refuses to dismiss a transgender man's discrimination claims against providers under Section 1557 of the Affordable Care Act
  Rumble v. Fairview Health Servs.
  
  
• District Court dismisses hospital's $30 million claim against New Jersey Medicaid managed care organization
  MHA, LLC v. Healthfirst, Inc.
  
  
• The California Supreme Court finds that residential care citation records should Be released and (minimally) redacted pursuant to the Long-Term Care Act – not the Lanterman Act.
  State Dep't of Pub. Health v. Superior Court of Sacramento Cnty.
  
  
• Partners drops acquisition after court rejects antitrust settlement
  Commonwealth v. Partners Healthcare System, Inc. et. al.
  
  

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March 2015 Managed Care Lawsuit Watch [full version]

• California Court of Appeals Refuses to Certify a Class of Uninsured Patients Receiving Emergency Care
  Hale v. Sharp Healthcare
  
  
• District Court Refuses to Dismiss an ERISA Plan Administrator’s Counterclaim Against Out-of-Network Provider
  Nutrishare, Inc. v. Connecticut Gen. Life Ins. Co.
  
  
• South Carolina District Court Denies Attempt by Provider to Negate Mandatory Arbitration Provision Through ERISA Derivative Standing
  Greenville Hosp. Sys. v. Employee Welfare Benefits Plan for Employees of Hazlehurst Mgmt. Co. Underwritten by Aetna Life Ins. Co.
  
  
• Florida District Court Dismisses Qui Tam Action That Alleged Fraud Under Medicare Advantage Program
  U.S., ex rel. Graves v. Plaza Med. Centers Corp.
  
  
• District Court in New York Dismisses Suit Against Omnicare Brought by "Serial Qui Tam Relator" and Former Part D Plan Sponsor
  U.S., ex rel. Fox Rx, Inc. v. Dr. Reddy's Inc.
  
  
• Louisiana District Court Upholds Medicare Advantage Plan’s Right to Reimbursement from Beneficiary’s Tort Settlement
  Collins v. Wellcare Healthcare Plans, Inc.
  
  
• Federal Court in District of Columbia Refuses to Exercise Mandamus Powers to Clear Backlog of Appeals Challenging Medicare Claim Denials
  American Hospital Ass'n v. Burwell
  
  
• New Jersey District Court Refuses to Dismiss a Qui Tam Action on Allegedly Illegal Medicare Part A and Medicare Part D “Swapping”
  U.S., ex rel. Silver v. Omnicare, Inc., et. al.
  
  
• FTC Requires Divestiture from Florida ASC Prior to Merger of ASC Chains
  In the Matter of H.I.G. Bayside Debt & LBO Fund II, L.P. and Crestview Partners, L.P.
  
  
• Unpublished D.C. Circuit Opinion Holds That Affirmative Action Requirements for Government Subcontractors Do Not Apply to Certain Hospitals
  UPMC Braddock v. Perez
  
  

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October 2014 Managed Care Lawsuit Watch [full version]

• U.S. Court of Appeals holds that a provider can bring a private cause of action under the Medicare Secondary Payer Act against a primary non-group health plan that denies coverage on a basis other than Medicare eligibility.
  Michigan Spine and Brain Surgeons, PLLC v. State Farm Mutual Automobile Insurance Co.
  
  
• U.S. Court of Appeals affirmed dismissal of a suit arguing ERISA preemption of state health insurance tax.
  Self-Insurance Institute of America, Inc. v. Snyder
  
  
• Federal District Court rules that providers are not ERISA beneficiaries.
  DB Healthcare, LLC v. Blue Cross Blue Shield of Arizona
  
  
• Central District of California granted a motion to dismiss, holding that the Secretary of Health and Human Services could apply the "Copay-First Approach" to administer Medicare Part D "donut hole" claims.
  Epstein v. Burwell
  
  
• Northern District of California dismissed antitrust claims against Sutter Health because the plaintiffs failed to allege a geographic market under the Sherman Act.
  Sidibe et al v. Sutter Health
  
  
• District Court holds that HHS' dismissal of hospital's appeal was arbitrary.
  University of Chicago Medical Center v. Sebelius
  
  
• District Court upholds existing framework for analyzing "falsity" in kickback-based false claims cases.
  U.S. ex rel. Kester v. Novartis Pharmaceuticals Corp.
  
  
• California appellate court holds that, under last year’s Ninth Circuit decision, federal law does not require states to consider provider costs when setting Medicaid reimbursement rates.
  Tim Keffeler v. Partnership HealthPlan of California
  
  

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July 2014 Managed Care Lawsuit Watch [full version]

• Nevada Supreme Court affirms trial court dismissal of a negligence action by a Medicare Advantage plan member against the plan finding that the claim was preempted by the Medicare Act.
  Louis Morrison v. Health Plan of Nevada, Inc.
  
  
• U.S. Court of Appeals holds medical device companies not subject to mandatory arbitration clause in dispute with insurer, overturning lower court.
  CardioNet, Inc.v. Cigna Health Corp.
  
  
• Arizona Court of Appeals finds that Medicare Advantage plans may seek reimbursement for expenses paid for an enrollee from the settlement of claims that sought compensation for those expenses on behalf of the enrollee.
  Estate of Ethridge v. Recovery Mgmt. Sys.
  
  
• U.S. District Court grants an injunction requiring defendant Independence Blue Cross to bolster its ERISA compliance regarding notice and appeal procedures when seeking recovery of overpayments to providers.
  Pennsylvania Chiropractic Association v. Blue Cross Blue Shield Association
  
  
• U.S. Court of Appeals holds that complete preemption does not exist under the Federal Employees Health Benefits Act.
  Raquel Lopez-Munoz v. Triple-S Salud, Inc.
  
  
• U.S. District Court holds that OPM and FEBHP are immune from compliance with the California Mental Health Parity Act.
  Brazil v. Office of Personnel Management
  
  
• U.S. District Court denies injunction to block allergists from attempts to convince insurers to limit certain medical services to allergists.
  Academy of Allergy & Asthma in Primary Care v. American Academy of Allergy, Asthma, & Immunology
  
  
• California court requires insurer to provide medically-necessary treatment to people with eating disorders.
  Rea v. Blue Cross Blue Shield of California
  
  
• The California Court of Appeal rules that DHMC cannot uphold denials of certain autism coverage on the grounds that a therapist is not licensed by the state.
  Consumer Watchdog v. DMHC
  
  

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April 2014 Managed Care Lawsuit Watch [full version]

• New York Appellate Division holds that Prompt Pay Law provides claimants an implied private cause of action.
  Maimonides Med. Ctr. v. First United Am. Life Ins. Co.
  
  
• The Ninth Circuit upholds CMS's decision to reduce a provider's annual reimbursement for untimely submission of certain data.
  PAMC v. Sebelius
  
  
• U.S. District Court denied a motion to dismiss counterclaims for payment for services, rejecting the plaintiff's argument that a counterclaim based on state law theories of negligent misrepresentation and promissory estoppel is preempted by ERISA.
  Connecticut General Life Insurance Company v. Grand Avenue Surgical Center, Ltd. .
  
  
• Humana reaches settlement agreement regarding alleged bundled medical and life insurance sales.
  In Re Humana Insurance Company (Regulatory Settlement Agreement)
  
  
• U.S. Court of Appeals affirmed the removal and dismissal of an out-of-network provider's reimbursement suit, holding that the implied breach of contract claim was completely preempted by ERISA and barred by Federal Rule of Civil Procedure 41(a)(1)(B)'s "two dismissal" rule.
  Melamed v. Blue Cross of California
  
  
• Two orthopedic clinics settled with federal authorities for submitting claims to federal health care programs for reimported medications.
  United States ex rel. Estey v. Tennessee Orthopaedic Clinics PC et al.
  
  

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February 2014 Managed Care Lawsuit Watch [full version]

• U.S. Court of Appeals reverses the denial of plaintiffs' motion for preliminary injunction and remanded to the district court, holding that two for-profit family businesses operating according to a set of Christian principles were "persons" entitled to standing under the Religious Freedom Restoration Act (RFRA).
  Sebelius v. Hobby Lobby Stores, Inc.
  
  
• U.S. Court of Appeals affirms the denial of the plaintiffs' motion for a preliminary injunction, holding that for-profit, secular corporations are unable to engage in religious exercise under the Free Exercise Clause and are not "persons" with standing under the Religious Freedom Restoration Act (RFRA).
  Conestoga Wood Specialties v. Sebelius
  
  
• AvMed settles privacy breach class action lawsuit for $3 million even though not all plaintiffs could demonstrate cognizable harm.
  Curry et al., v. AvMed, Inc.
  
  
• Federal Trade Commission wins antitrust challenge to block health system's acquisition of an independent physician practice.
  St. Alphonsus Medical Center-Nampa et al. v. St. Luke's Health System Ltd.
  
  
• Florida appellate court affirms lower court's denial of motion to compel arbitration asserted by CarePlus.
  CarePlus Health Plans, Inc. v. Interamerican Medical Center Group, LLC
  
  
• U.S. District Court dismisses lawsuit accusing University of Pittsburgh Medical Center and Highmark of anti-competitive agreement to inflate consumer premiums.
  Royal Mile Co., Inc., et al. v. UPMC et al.
  
  
• Pennsylvania reaches consent agreement with Geisinger Health System to allow acquisition of hospital pursuant to conduct remedies.
  Commonwealth of Pennsylvania v. Geisinger Health System Foundation, Lewistown Health Care Foundation
  
  
• In three separate opinions, U.S. District Court for the Northern District of Illinois grants summary judgment or partial summary judgment to chiropractors who alleged that the defendant health plans violated ERISA by recouping overpayments without providing the chiropractors ERISA-mandated notice and appeal rights.
  Pennsylvania Chiropractic Assoc. v. Blue Cross Blue Shield Assoc.
  
  
• U.S. District Court denies a motion to dismiss billing claims against a provider, holding that CIGNA v. Amara does not preclude reliance on a summary plan document where its terms do not conflict with governing plan documents.
  Connecticut General Life Insurance Company v. Roseland Ambulatory Center LLC
  
  
• U.S. Court of Appeals reverses summary judgment, remands to determine whether Concert Health Plan breached its fiduciary duty by not informing plaintiff about network coverage.
  Killian v. Concert Health Plan
  
  

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October 2013 Managed Care Lawsuit Watch [full version]

• Federal and Illinois antitrust claims over exclusive agreement between hospital services provider and insurance company fail
  Marion Healthcare LLC v. Southern Illinois Healthcare
  
  
• U.S. District Court granted motions to dismiss complaint alleging conspiracy by health plan and employee unions to eliminate competing hospitals from health care services market.
  Prime Healthcare Services, Inc. v. Kaiser Foundation Health Plan, Inc. et al.
  
  
• United States District Court dismissed with prejudice an antitrust monopsony claim brought by a group of pharmacies and pharmacy industry associations to enjoin the merger of two pharmaceutical benefits management companies.
  National Community Pharmacists Assoc. v. Express Scripts, Inc.
  
  
• U.S. Court of Appeals affirmed dismissal of complaint alleging RICO violations by pharmaceutical manufacturer and Walgreens, holding that Plaintiffs failed to adequately allege that Defendants conducted their affairs on behalf of a RICO enterprise.
  United Food and Commercial Workers Unions and Employers Midwest Health Benefits Fund v. Walgreen Co.
  
  
• Missouri District Court grants Humana's motion to dismiss plan participant's claim because FEHBA required plaintiff to exhaust his administrative remedies.
  Barnes v. Humana, Inc.
  
  
• Class action litigation alleging that WellPoint, UHG and Ingenix database platform service conspired to underpay for out-of-network care continues after motion to dismiss is granted in part but denied in part.
  In re WellPoint, Inc. Out-of-Network "UCR" Litigation
  
  
• California appeals court rules that state health care regulators must ensure that plans cover autism therapy provided by certified, but unlicensed, professionals.
  Consumer Watchdog v. California Department of Managed Health Care
  
  

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July 2013 Managed Care Lawsuit Watch [full version]

• The United States Court of Appeals for the Ninth Circuit upheld CMS's immediate termination of a Medicare Part D contract with prescription drug plan sponsor Fox Insurance Company, Inc. after CMS determined that it was delaying or denying beneficiary access to drugs.
  Fox Ins. Co., Inc. v. Centers for Medicare & Medicaid
  
  
• Two federal district courts reach opposite conclusions from similar facts on ERISA preemption of plan recoupment claims.
  Aflac, Inc. v. Bloom; Fustok v. UnitedHealth Group, Inc. et al.
  
  
• United States District Court dismisses complaint alleging pharmaceutical companies violated federal racketeering and antitrust laws through programs by which they offer to cover the cost of co-payment obligations for their branded drugs.
  Am. Federation of State, County and Municipal Employees District Council 37 Health & Security Plan v. Bristol Myers Squibb Co.
  
  
• The United States Court of Appeals for the Ninth Circuit affirmed a grant of summary judgment holding that a Medicare Advantage Organization plan could not sue a plan participant's survivors for reimbursement of medical expenses from the automobile insurance wrongful death proceeds received by the relatives.
  Parra v. PacifiCare of Arizona
  
  
• United States District Court rules against plaintiff in ERISA action, granting motions to compel arbitration and to dismiss in favor of insurer and third-party administrators.
  MRI Scan Center, LLC v. National Imaging Assocs., Inc, et. al
  
  
• United States District Court held that under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Parity Act), plan administrators bear the burden of establishing why mental health benefits are treated differently from medical benefits based upon divergent clinical standards.
  C.M. v. Fletcher Allen Health Care, Inc. and the Fletcher Allen Preferred Plus Medical Plan
  
  
• United States District Court granted defendants' motion to enforce an injunction prohibiting further litigation by providers regarding reimbursement for health care services by managed care companies.
  Love v. Blue Cross and Blue Shield Association
  
  
• Texas Supreme Court rules that a lack of privity between hospitals and Aetna precludes a suit alleging a violation of the Prompt Pay Statute.
  Christus Health Gulf Coast, et al. v. Aetna, Inc. and Aetna Health, Inc.
  
  
• United States District Court constructs its own class definition and grants a motion for certification of an injunctive class for a group of providers suing over contract interpretation.
  Chehalem Physical Therapy, Inc. and South Whidbey Physical Therapy and Sports Clinic v. Coventry Health Care, Inc.
  
  
• The federal government intervened in a False Claims Act lawsuit alleging that Novartis issued kickbacks to pharmacies.
  United States v. Novartis Pharmaceuticals Corp.
  
  

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May 2013 Managed Care Lawsuit Watch [full version]

• Because a Michigan law banning most-favored-nation contract clauses renders the case unnecessary, the U.S. Department of Justice, State of Michigan, and Blue Cross Blue Shield of Michigan jointly ask Michigan federal court to dismiss an ongoing lawsuit.
  United States v. Blue Cross Blue Shield of Michigan
  
  
• Supreme Court resolves Circuit split, holding that when an ERISA plan brings equitable action under § 502(a)(3) to enforce an equitable lien by agreement, equitable defenses cannot be asserted if they conflict with the terms of the plan.
  U.S. Airways, Inc. v. McCutchen
  
  
• U.S. District Court denies motion to dismiss False Claims Act allegations.
  U.S., ex rel. Upton v. Family Health Network, Inc.
  
  
• U.S. District Court denied Plaintiff's motion for summary judgment and granted summary judgment in favor of PacifiCare, finding that a California statute mandating an offer of coverage for prosthetic devices permits health plans to categorically exclude certain types of prosthetic devices.
  Garcia v. Pacificare of California, Inc.
  
  
• The Circuit Court of Jackson County, MO permitted Humana to collect against plaintiff's personal injury settlement by subrogation and granted Humana's motion for summary judgment.
  Morris v. Humana Health Plan, Inc.
  
  
• The First Circuit ruled against Pfizer in three separate cases involving claims that fraudulent marketing of Neurontin by Pfizer caused third-party payors financial harm.
  In re Neurontin Marketing and Sales Practices Litigation
  
  
• U.S. District Court denied a health plan's motion for summary judgment that was based on an argument that an Independent Review Organization's claim denial review is an arbitration.
  Yox v. Providence Health Plan
  
  
• U.S. Court of Appeals affirms a grant of summary judgment holding that an insurer could deny coverage for the medically necessary treatment provided at a nonparticipating facility.
  Brigolin v. Blue Cross Blue Shield of Michigan
  
  
• U.S. District Court declined to grant class certification in a reimbursement suit against multiple health insurers.
  Puerto Rico College of Dental Surgeons v. Triple S Management
  
  
• District court holds state law claims completely preempted under ERISA where coverage was denied based on medical necessity of a drug.
  S.M. v. Oxford Health Plans (NY), Inc.
  
  
• Federal law preempts North Carolina's statutory presumption as applied to recovery of Medicaid expenses.
  WOS v. E.M.A.
  
  

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February 2013 Managed Care Lawsuit Watch [full version]

• U.S. Supreme Court rules unanimously that state action doctrine does not provide immunity from federal antitrust law for Georgia entity's creation of allegedly monopolistic regional hospital system.
  FTC v. Phoebe Putney Health System, Inc.
  
  
• New Jersey Federal District Court dismisses suit of hospital system claiming assignment-based standing under ERISA.
  MHA, LLC v. Aetna Health, Inc. et al.
  
  
• Eighth Circuit rules that FEHB health plan can remove subrogation dispute to federal court pursuant to federal officer removal statute.
  Jacks v. Meridian Resource Co., LLC & Blue Cross Blue Shield of Kansas City
  
  
• 7th Circuit affirms insured's statutory penalty award under ERISA .
  Mondry v. American Family Mutual Insurance Company
  
  
• Fifth Circuit Court of Appeals Vacates the District Court's Award of $43 Million to Insurers for Health Care Fraud.
  United States v. Sharma
  
  
• U.S. District Court denied motion for preliminary injunction to prevent acquisition by a rival medical center.
  Saint Alphonsus Medical Center – Nampa, Inc., et al. v. St. Luke's Health System, Ltd.
  
  

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December 2012 Managed Care Lawsuit Watch [full version]

• Federal appeals court holds that a plan administrator's decision to deny coverage for attention-deficit hyperactivity disorder therapy and testing was not arbitrary and capricious.
  Christoff v. Ohio Northern University Employee Benefit Plan
  
  
• U.S. Appellate Court upholds dismissal of a class action complaint for Plaintiffs' failure to plead particularized facts demonstrating that a "manipulation under anesthesia" procedure was medically necessary and not experimental under the relevant health insurance policies.
  Advanced Rehabilitation, LLC v. UnitedHealth Group, Inc.
  
  
• SDNY grants motion of Medicare Advantage plans to dismiss suit for declaratory judgment as to New York law prohibition on subrogation rights vis-à-vis beneficiary settlements with third parties.
  Potts v. The Rawlings Company, LLC
  
  
• Kentucky Court of Appeals consolidates and reverses trial court's Medicaid AWP decisions, rescinding $30 million of damages awards.
  Sandoz, Inc. v. Kentucky ex rel. Conway; AstraZeneca, LP v. Kentucky ex rel. Conway
  
  
• Federal antitrust authorities approve Humana Inc.'s acquisition of Acadian Management Services, Inc., pending divestiture of some Medicare Advantage assets.
  United States v. Humana Inc.
  
  
• U.S. Appellate Court upholds denial of enforcement of subrogation clause against law firm representing bankrupt beneficiary
  Treasurer, Trustees of Drury Industries, Inc. Health Care Plan and Trust v. Sean Goding; Casey & Devoti, P.C.
  
  
• District Court denies motion to dismiss health plan's antitrust and tortious interference claims against health providers
  Humana Health of Puerto Rico, Inc. v. Vilaro
  
  

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July 2012 Managed Care Lawsuit Watch [full version]

• U.S. Supreme Court upholds Affordable Care Act, including "tax" for those who elect not to buy coverage, but strikes withholding of Medicaid funds to states that do not adopt Medicaid expansion
  U.S. Supreme Court Health Care Reform Decision: National Federation of Independent Business v. Sebelius
  
  
• Third Circuit finds that Medicare Advantage Organizations have private cause of action when acting as secondary payers; rules in favor of Humana on costs of care for Avandia-related injuries
  GlaxoSmithKline, LLC et al. v. Humana Medical Plan, Inc., et al.
  
  
• U.S. District Court denies Blue Cross's motion to dismiss antitrust challenge for allegedly exclusionary contracting scheme
  Aetna, Inc. v. Blue Cross Blue Shield of Michigan
  
  
• Divided 9th Circuit panel withdraws earlier decision, retains ruling that Mental Health Parity Act requires coverage of residential treatment for anorexia nervosa
  Harlick v. Blue Shield of California
  
  
• Texas's Supreme Court upholds state insurance department's treatment of self-funded employee benefit plan's stop loss insurance as health insurance (and not as reinsurance)
  Texas Dep't of Ins. v. Am. Nat'l Ins. Co.
  
  
• U.S. District Court grants a motion to dismiss various claims brought to challenge denial of full reimbursement for durable medical equipment
  Pellicano v. Blue Cross Blue Shield Association
  
  
• U.S. District Court rules that insurers' termination of coverage for New Life Homecare employees did not violate ERISA
  New Life Homecare, Inc. v. Blue Cross of Northeastern Pennsylvania
  
  
• Federal District Court denies in part motion to dismiss claims brought by Fox Insurance Company against Humana
  Fox Ins. Co. Inc. v. Humana Inc.
  
  
• Federal District Court for the Southern District of Texas rejects Blue Cross Blue Shield of Texas's motion to dismiss claims for $12 million of alleged underpayments
  Mid-Town Surgical Center, LLP v. Blue Cross Blue Shield of Texas, Inc.
  
  
• Third Circuit holds that under ERISA § 502(a)(3), beneficiaries may assert equitable defenses and limitations in actions seeking full reimbursement
  US Airways, Inc. v. McCutchen
  
  
• Walgreens settles alleged False Claims Act violations for $9.2 million
  United States ex rel. Cass v. Walgreens Pharmacy
  
  
• Settlement with WellCare over Medicaid fraud allegations yields at least $135.7 million for federal and state governments
  Settlement Agreement Between WellCare Health Plans, Inc. et al. and State of Connecticut and others Relating to Medicaid False Claims Allegations
  
  
  

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April 2012 Managed Care Lawsuit Watch [full version]

• California court permits plaintiffs to seek punitive damages for contract and tort claims arising from health plan's alleged "system of withholding benefits"
  Kaiser Foundation Health Plan, Inc. v. Superior Court
  
  
• ERISA Preempts Texas Prompt Pay and PPO Contract Claims
  Markey, M.D. v. Aetna Health Inc.
  
  
• Seventh Circuit vacates district court's denial of motion for class certification in antitrust suit alleging harm from higher prices after hospitals' merger
  Messner v. Northshore University Healthsystem
  
  
• Maine Supreme Court upholds rejection of proposed 9.2% premium increases on individual coverage as "excessive and unfairly discriminatory"
  Anthem Health Plans of Maine, Inc. v. Superintendent of Insurance
  
  
• U.S. District Court dismisses pharmacy cooperative's suit, finding that cooperative could have sought relief through administrative process to pursue claim regarding "any willing provider" provisions of Medicare Part D law
  Sw. Pharmacy Solutions, Inc. v. CMS
  
  
• U.S. District Court grants state's motion to vacate longstanding consent decree on state provision of EPSDT services to children under state Medicaid program
  John B. v. Emkes
  
  
• Federal district court determines that ERISA does not preempt provider's action to recover from health plan on promissory estoppel theory
  The Oak Brook Surgical Center v. Aetna Health, Inc.
  
  
• Federal Trade Commissioners vote to adopt ALJ's findings and ruling and order ProMedica to divest its interest in St. Luke's Hospital
  In the matter of ProMedica Health System, Inc.
  
  
• HHS reviews and rejects rates proposed by Trustmark Life Insurance Company for individual coverage markets in five states
  HHS Rate Review of Trustmark Life Insurance Company
  
  

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October 2011 Managed Care Lawsuit Watch [full version]

• U.S. District Court Denies Plaintiff's Motion To Remand Because The Class Action Fairness Act's Location Controversy Exception Is Not Jurisdictional
  Calingo v. Meridian Res. Co.
  
  
• U.S. District Court Finds That Enrollee's State Law Claims Against Her Medicare Advantage Plan Are Preempted By The Medicare Act
  Phillips v. Kaiser Foundation Health Plan Inc., et al.
  
  
• Eleventh Circuit Rules Individual Mandate In The Patient Protection And Accountable Care Act ("ACA") Is Unconstitutional But Severable; Upholds Expansion Of Medicaid Program Under ACA
  State of Florida, et al. v. United States Department of Health and Human Services, et al.
  
  
• Second Circuit Affirms Grant Of Summary Judgment And Denial Of New York City's Motion To Amend Its Complaint
  City of New York v. Group Health Incorporated, HIP Foundation, Inc., and Health Insurance Plan of Greater New York
  
  
• Tenth Circuit Defers To OPM's Interpretation Of FEHB Plan's Terms, But Reverses And Remands Trial Court Affirmance Of OPM's Decision Insofar As OPM Adopted A Health Benefits Carrier's Calculation Of Benefits Without Confirming The Calculation's Validity
  Weight Loss Healthcare Centers of America, Inc. v. Office of Personnel Management
  
  
• District Court Denies Blue Cross Blue Shield of Michican's 12(B)(6) Motion To Dismiss Antitrust Claims Brought By The U.S. And The State Of Michigan Over The Use Of Most Favored Nations Clauses In Healthcare Contracts
  United States of America and State of Michigan v. Blue Cross Blue Shield of Michigan
  
  
• U.S. Appellate Court Affirmed Dismissal Of Health Reform Challenge, Finding That Plaintiff Failed To Plead An Injury In Fact And Therefore Lacked Standing
  New Jersey Physicians, Inc. v. President of the United States
  
  
• A Federal Court Allows Several Claims Against Insurers Involving Out-Of-Network Reimbursement Rates To Continue
  In re WellPoint, Inc. Out-of-Network "UCR" Rates Litigation
  
  
• Geisinger & Shamokin Merger Approved With Conditions To Protect Medicare Advantage Patients
  Commonwealth v. Geisinger Med. Ctr. & Shamokin Area Cmty. Hosp.
  
  
• Ninth Circuit Rules That California Mental Health Parity Act Requires Health Plan To Cover All "Medically Necessary Treatment" For "Severe Mental Illnesses" Enumerated In The Statute
  Harlick v. Blue Shield of California
  
  
• U.S. District Court Denies Motion To Dismiss Provider Claims Alleging That Blue Cross Blue Shield Of Texas Failed To Pay For Services And Improperly Attempted To Recoup Prior Compensation
  Fisher v. Blue Cross Blue Shield of Texas
  
  
• Federal District Court In Philadelphia Certifies One Plaintiff Class But Refuses To Certify Another In ERISA Action Brought Against Health Insurer By Plaintiffs Seeking Reimbursement Of Treatments For Autism
  Churchill v. CIGNA Corp.
  
  
• Nevada Supreme Court Rules That Arbitration Provision In Medicare Advantage Plan's Contract With A Beneficiary Survives The Contract, Should Be Enforced, And Is Not Subject To The State Common Law Doctrine Of Unconscionability
  PacifiCare of Nevada, Inc. v. Rogers
  
  
  

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July 2011 Managed Care Lawsuit Watch [full version]

• U.S. Appellate Court reverses order for Blue Cross Blue Shield of Michigan to disclose claims-related discount information
  Pipefitters Local 636 Insurance Fund v. Blue Cross & Blue Shield of Michigan
  
  
• Louisiana Supreme Court reinstates $180 million judgment against former owner of HMOs
  Wooley v. Lucksinger
  
  
• Third Circuit Permits One Count of Case against Medicaid Managed Care Plan to Proceed on Implied False Certification Theory of FCA Liability
  United States ex rel. Charles Wilkins v. United Health Group, Inc.
  
  
• Federal court upholds denial of coverage for "experimental" migraine treatment
  Lees v. Harvard Pilgrim Health Care of New England
  
  
• District Court for the Southern District of Ohio compels physician group's subsidiary, OSU Pathology, to arbitrate with Aetna over claims submitted as if OSU Pathology were an out-of-network provider
  OSU Pathology Services, LLC v. Aetna Health, Inc.
  
  
• FTC wins PI, imposing terms of Hold Separate Agreement on ProMedica's acquisition of competing Toledo hospital
  FTC v. ProMedica Health System, Inc.
  
  
• Court says ERISA does not preempt state law claim for alleged violation of right to privacy
  Quintana v. Lightner
  
  
• Report finds nuclear cardiac imaging pre-authorization practices of Blue Cross Blue Shield of Delaware, Inc. in violation of state law
  Market Conduct Examination Report on BCBSD, Inc.
  
  

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May 2011 Managed Care Lawsuit Watch [full version]

• Federal Appellate Court Dismisses Insured's Claim that Insurer had "Improperly and Arbitrarily" Chosen a Reimbursement Methodology that Minimized the Insurer's Financial Responsibility
  Lieberman v. United Healthcare Insurance Co.
  
  
• Eighth Circuit Rules that Plan Participant May Be Responsible for Amounts Above the Out-of-Pocket Maximum
  Kitterman. v. Coventry Health Care of Iowa, Inc.
  
  
• Eighth Circuit Holds ERISA Administrator's Denial of Benefits Constituted an Abuse of Discretion
  Wrenn v. Principal Life Insurance Co.
  
  
• Florida Federal Court Issues Order to Stay Declaratory Judgment Against Health Reform Law
  Florida v. United States Dep't of Health & Human Servs., et al.
  
  
• Summary Judgment Denied for Two of Three Contract Claims in Pharmacy Benefits Reimbursement Suit Between Coventry Health Care Inc. and Caremark Inc.
  Coventry Health Care, Inc. v. Caremark, Inc.
  
  
• United Regional Health Care System of Wichita Falls, Texas Agrees to Cease Using Exclusionary Contracting Tactics with Commercial Payer to Resolve Antitrust Claims by Department of Justice and Texas Attorney General.
  United States v. United Regional Health Care System
  
  
• State and Federal Government Reach $25 Million Settlement with BlueCross and BlueShield of Illinois Regarding Allegations of Fraudulent Coverage Denials for Private Duty Skilled Nursing Benefits to "Medically Fragile" Children
  Settlement Agreement between BlueCross and BlueShield of Illinois, Health Care Service Corporation, the United States, and State of Illinois
  
  
• South Carolina District Court Refuses Motion to Dismiss Due to "Novel" ERISA Issues in Reimbursement Suit
  Hornady Transportation, et al. v. McLeod Health Services Inc., et al.
  
  
• Sportscare of America's Motion to Remand Is Denied Due to ERISA Preemption of State Claims
  Sportscare of America, P.C. v. Multiplan, Inc.
  
  
• Refusal to Cover Residential Mental Health Treatment Held Not to Violate ERISA or California Parity Act
  Daniel F. v. Blue Shield of California
  
  
• Texas Federal Judge Rejects Most of CIGNA's Arguments in Motion to Dismiss Claims Brought for Underpayment and Flawed Calculation of Benefits Owed to an Out-of-Network Hospital
  North Cypress Medical Center Operating Co. v. CIGNA Healthcare
  
  
• Court Holds that Claims for Monetary Relief Do Not Qualify as "Appropriate Equitable Relief" under ERISA
  Kenseth v. Dean Health Plan, Inc.
  
  
• Federal Statute and Regulations Concerning TRICARE Health Insurance Program Preempt Hospital's State Law Claim to Recover Hospital Lien for Care Provided
  MCG Health, Inc. v. Owners Insurance
  
  
  

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March 2011 Managed Care Lawsuit Watch [full version]

• Insurance Company Permitted to Deduct Overpayments to Provider from Subsequent Payments Owed for Different Patients Under Different Plans
  Quality Infusion Care, Inc. v. Health Care Service Corporation
  
  
• The United States District Court for the Northern District of Florida Declares the Patient Protection and Affordable Care Act Unconstitutional
  Florida, et al. v. United States Department of Health & Human Services, et al.
  
  
• Mississippi Federal Court Dismisses Suit Challenging PPACA's Minimum Essential Coverage Provision on Jurisdictional Grounds
  Bryant, et al. v. Holder, et al.
  
  
• District Court Dismisses Claims Against United Healthcare of the Midwest in Continuation of Schoedinger Suit
  Schoedinger v. United Healthcare of the Midwest, Inc.
  
  
• District Court for the Southern District of California Dismisses Humana's Claim for Reimbursement of Benefits Paid for Lack of Subject Matter Jurisdiction
  Humana Med. Plan, Inc. v. Reale
  
  
• Medical Center's Claims Related to Underpayments Are Not Preempted by ERISA
  San Ramon Regional Medical Center Inc. v. Principal Life Insurance Co.
  
  
• Federal Employee's State Medical Malpractice Claims Against Health Insurer Held Not Removable Absent Complete Preemption by the Federal Employees Health Benefits Act ("FEHBA")
  Farnsworth v. Harston
  
  
• Court Denies Dentists' Motion to Remand Based on Exceptions to Class Action Diversity Jurisdiction
  College of Dental Surgeons of Puerto Rico v. Triple S Management, Inc.
  
  
• District Court Dismisses Due Process Allegations Against Medicare Advantage Plan; Remands State Law Claims
  Kovach v. Coventry Health Care, Inc.
  
  
• Court Upholds Denial of Benefits under the Federal Employees Health Benefits Act
  Colicchio v. Office of Personnel Management
  
  
• California Agency Faces No Statutory Obligation That Would Require Managed Care Plans to Cover "Medically Necessary" Applied Behavioral Analysis ("ABA") Autism Treatment from Unlicensed Specialists
  Consumer Watchdog v. California Department of Managed Health Care
  
  
• Managed Care Contractor, CareSource, Settles False Claims Act Allegations with United States and Ohio for $26 Million
  United States ex rel. Laura Rupert and Robin Herzog v. Caresource Management Group, Co.
  
  
• $2 million Settlement Resolves Charges Regarding False HEDIS Scores Submitted for Kentucky's Medicaid Program
  AmeriHealth Mercy
  
  
  

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February 2011 Managed Care Lawsuit Watch [full version]

• Third Circuit Reverses Dismissal of Hospital System's Antitrust Suit Against Competing Hospital System and Health Insurance Plan
  West Penn Allegheny Health System Inc. v. UPMC
  
  
• Sixth Circuit Rules Insurer Was Not Acting As a Fiduciary Under ERISA When Negotiating Reimbursement Rates
  DeLuca v. Blue Cross Blue Shield of Michigan
  
  
• 7th Circuit Affirms Summary Judgment In Favor of UnitedHealth Group, Rejecting Omnicare's Antitrust and Fraud Claims
  Omnicare, Inc. v. UnitedHealth Group, Inc.
  
  
• Coventry Healthcare of Kansas Granted Partial Judgment in Copayment Case
  Holling-Fry v. Coventry Healthcare of Kansas, Inc.
  
  
• State Marketing Laws Preempted by Federal Medicare Advantage Marketing Rules
  Arcadian Health Plan v. Korfman
  
  
• District Court Finds Humana Operates "Under Color of Federal Law" as Medicare Advantage Plan Sponsor; Denies Plaintiffs' Motion to Remand
  Mann v. Reeder
  
  
• Anthem Pays $1.62 to Settle Claims
  Anthem Blue Cross of California Settlement
  
  
• Federal Court Finds Plaintiff's Claims Preempted by ERISA
  Merziotis v. Kaiser Foundation Health Plan
  
  
  

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December 2010 Managed Care Lawsuit Watch [full version]

• Federal Court Rules PPACA's Minimum Essential Coverage Provision Unconstitutional
  Commonwealth of Virginia v. Sebelius
  
  
• Federal Court Rules that Florida's Challenge to PPACA Can Proceed
  State of Florida v. United States Department of Health & Human Services
  
  
• Michigan court upholds PPACA "Individual Mandate"
  Thomas More Law Center v. Obama
  
  
• Federal Court Rules that Oklahoma Law Allows the Exclusion of Pre-Existing Congenital Anomalies of a Covered Dependent Child in Certain Types of Policies
  Oldenkamp v. United American Ins. Co.
  
  
• District Court Enters Final Order Approving Attorneys Fees in Class Action Settlement Against Insurer Alleging Underpayments Based on Improper "Usual Customary and Reasonable" Charges
  The American Medical Association v. United Healthcare Corporation
  
  
• Plaintiffs' Denial of Benefits Claims Dismissed in Federal Court
  Lewis v. Aetna Ins. Agency Inc.
  
  
• ALJ Holds Hospital Contracting with TRICARE Contractor Is Subject to Affirmative Action and Non-Discrimination Statutes
  Office of Federal Contract Compliance Programs, United States Department of Labor v. Florida Hospital of Orlando
  
  
• Court Refuses to Enjoin Termination of Provider Agreement by MBHO
  Cumberland Heights Foundation, Inc. v. Magellan Behavioral Health, Inc.
  
  
• Federal Court Rules that Blue Cross Plan Permissibly Increased Premiums of an Employer Group Purchasing Health Insurance Through a Group Purchasing Arrangement
  Fossen v. Blue Cross Blue Shield of Montana, Inc.
  
  
  

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September 2010 Managed Care Lawsuit Watch [full version]

• Ninth Circuit Affirms Dismissal Of Claims As Preempted by the Medicare Act
  Uhm v. Humana, Inc.
  
  
• Federal Court Finds Certain Provisions of Title II of D.C.'s Access Rx Act of 2004 Preempted by ERISA
  Pharmaceutical Care Mgmt. Assoc. v. District of Columbia
  
  
• Court Holds Physicians' Claims Barred by Prior Settlement Agreement
  Shane v. Humana (In re Managed Care)
  
  
• Colorado Federal Judge Remands Breach Of Contract Case To State Court
  Memorial Health System v. Aetna Health, Inc.
  
  
• Suit Based on Insurer's Alleged Failure To Pay for Services Preempted by ERISA
  American Surgical Assistants, Inc. v. CIGNA Healthcare of Texas, Inc.
  
  
• Federal Court Rules that Plaintiff RNs Could Not Bring Their State Law Claims Under ERISA §502(a) and Denies Defendant's Notice of Removal to Federal Court
  Ramos v. Horizon Blue Cross Blue Shield of New Jersey
  
  
• Federal Court Denies Surgery Center's Claim for Reimbursement of Certain Fees, Finding That It Did Not Fall Within the Definition of "Other Health Care Facility" Found in Defendant's Policies
  Brunswick Surgical Center v. CIGNA
  
  
  

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August 2010 Managed Care Lawsuit Watch [full version]

• Eleventh Circuit Reinstates Dismissed Provider Claims Against Insurer for Underpayments
  Borrero v. United Healthcare of New York, Inc.
  
  
• Louisiana Appeals Court Approves $262 Million Class Action Settlement Between A Subsidiary of Coventry Health Care Inc. and Several Health Providers
  More...
  
  
• Eleventh Circuit Holds Competing Hospital Has Standing to Pursue Tying Claims
  Palmyra Park Hospital, Inc. v. Phoebe Putney Memorial Hospital
  
  
• Third Circuit Holds Formulary Change Does Not Violate ERISA
  Saltzman v. Independence Blue Cross
  
  
• Court Rejects Attempt by the City of New York to Unwind the Merger of Health Insurance Companies
  City of New York v. Group Health Inc., et al.
  
  
• Florida Court Holds Insurer's Right to Reimbursement Under Insurance Policy Limited by Florida Statute
  Ingenix v. Ham
  
  
• Federal District Court Remarks That Plan Language Is Insufficient to Grant Discretion to Administrator of a Health Plan
  Woodley v. Aetna Health Inc.
  
  
• Insurer's Right of Rescission Under ERISA Subject to Limitations Imposed by State Law
  Peterson v. First Health Life & Health Ins. Co.
  
  
  

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May 2010 Managed Care Lawsuit Watch [full version]

• Federal Court Upholds Sentencing of Two HMO Executives for Fraudulently Representing the Financial Condition of the HMO
  United States v. McMillan
  
  
• Court of Appeals Reverses Order Certifying Class of Hospitals in Suit Against TRICARE plan
  Sacred Heart Health Systems v. Humana Military Healthcare
  
  
• Court Partially Grants Motion to Dismiss Non-Participating Providers' Claims Brought Against Health Insurer
  Midwest Special Surgery v. Anthem Insurance Cos.
  
  
• Florida Court Holds that Medicare and Medicaid Reimbursement Rates Should Not Be Considered When Determining "Usual and Customary Provider Charges," but that Negotiated Rates with Other Payers May Be
  Baker County Medical Services Inc. v. Aetna Health Management
  
  
• District Court Refuses to Remand Provider's Claim for Reimbursement to State Court on the Basis of ERISA Preemption
  Spring E.R., LLC v. Aetna Life Insurance Company
  
  
• District Court Dismisses Dentist's § 1983 Claim Against Health Plan
  Monteleone v. United Concordia Companies
  
  
• California Court Holds that Several Common Law Claims Against a Medicare Advantage Health Plan Are Not Preempted by the Medicare Act
  Cotton v. Starcare Medical Group
  
  
  

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March 2010 Managed Care Lawsuit Watch [full version]

• FTC Settles Charges that Physicians' Association Director Evaded Previous Consent Order
  In Re Higgins
  
  
• Sierra Military Health Services Settles False Claims Act Allegations
  Sierra Military Health Services, LLC
  
  
• Court Upholds Insurance Policy Rescission by Reason of Policyholder's Material Misrepresentations and Omissions
  Nieto v. Blue Shield of California Life & Health Ins. Co.
  
  
• Court Allows Denial of Benefit Claim to Proceed and Dismisses All Other ERISA Related Claims
  Nationwide Children's Hospital, Inc. v. D.W. Dickey & Son, Inc. Employee Health and Welfare Plan
  
  
• Federal Judge Upholds Insurer's Denial of Autism Treatment
  McHenry v. PacificSource Health Plans, et al.
  
  
• Court Holds that Hospital Could Maintain Lien Against Medicare Beneficiary for the Patient's Cost of Treatment Instead of Billing Medicare
  Speegle v. Harris Methodist Health System & Harris Methodist Fort Worth
  
  
• Court Holds that Health Plan's Third-Party Administrator Could Potentially be Held Liable for Wrongful Denial of Benefits
  Nationwide Children's Hospital Inc. v. D.W. Dickey & Son, Inc. Employee Health and Welfare Plan
  
  
• Florida Court Holds Plaintiff Not Entitled to Damages Against Insurer for Breach of Contract
  Smith v. Florida Healthy Kids Corp.
  
  
  

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February 2010 Managed Care Lawsuit Watch [full version]

• Provider Claims Against Insurer for Underpayments Are Preempted by ERISA
  Connecticut State Dental Association v. Anthem Health Plans Inc.
  
  
• Court Allows Antitrust Claims to Proceed Against Ambulatory Surgery Center; Partially Grants Motion for Summary Judgment Regarding Tortious Interference Claims
  Peoria Day Surgery Center v. OSF HealthCare System
  
  
• Court Affirms District Court Ruling Dismissing a Cardiology Practice's Antitrust Claims Against Health Care Facility and HMO
  Little Rock Cardiology Clinic PA, et al. v. Baptist Health
  
  
• Court Rules Denial of Benefits Case Properly Dismissed
  Schermer v. BCBSM, Inc.
  
  
• Breach of Contract Suit Between Hospital and Health Plan Remanded to State Court
  John F. Kennedy Medical Center v. Dialysis Clinic Inc Group Health Plan
  
  
• Court Finds Hawaii's Medicaid Managed Care Program Does Not Violate the Medicaid Act; CMS Properly Reviewed Private Contracts Awarded to Administer the Program
  G., Parent and Next Friend of K. v. Hawaii Department of Human Services
  
  
  

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December 2009 Managed Care Lawsuit Watch [full version]

• Federal Court Grants Preliminary Approval of United Healthcare Class Action Settlement
  Am. Med. Ass'n v. United Healthcare Corp.
  
  
• Court Rules that Settlement Proceeds Are Not Plan Assets and Plan Member is Not a Fiduciary
  Health First Health Plans Inc. v. Glatter
  
  
• Federal Court Denies Class Certification, Grants Plaintiff Partial Summary Judgment
  Smith v. Life Investors Insurance Co. of America
  
  
• Court Remands Subrogation Case, Finds No Federal ERISA Preemption
  Cottrill v. Allstate Ins. Co.
  
  
• Court Finds California Health and Safety Code's HMO Standards Federally Preempted When Applied to a Medicare Advantage HMO
  Yarick v. Pacificare of California
  
  
• Claims Against Insurer for Cancellation of Coverage are Preempted by ERISA
  Grandcolas v. Healthy Alliance Life Ins. Co et al
  
  
• Maryland Court of Appeals Holds Coordination of Benefits in Policies Not Restricted
  MAMSI Life & Health Ins. Co. v. Wu
  
  
  

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November 2009 Managed Care Lawsuit Watch [full version]

• Court Rules Montana Can Bar Discretionary Clauses in ERISA Plans
  Standard Insurance Co. v. Morrison
  
  
• Eleventh Circuit Finds Policy Term Unambiguous, Affirms District Court
  Philadelphia American Life Insurance Co. v. Buckles
  
  
• CMS Submits Amicus Brief in Support of Medicare Preemption
  Uhm v. Humana Inc.
  
  
• Plan Ordered to Reconsider Coverage Denial for Newborn Air Transport
  Gilbert v. Med. Mutual of Ohio Co.
  
  
• Court Holds Insurer Abused Its Discretion Under ERISA by Denying Payment for a Procedure Deemed "Investigational"
  Welch v. HMO Louisiana/Blue Cross
  
  
• Court Dismisses Lawsuit Over the Cost and Calculation of a Portion of Insured's Premium
  Roussin v. AARP Inc.
  
  
  
  

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October 2009 Managed Care Lawsuit Watch [full version]

• Court Reverses Dismissal of Reimbursement Case; No Preemption Exists
  Marin General Hospital v. Modesto & Empire Traction Co.
  
  
• District Court Certifies Class in Action Against Insurer Alleging Fiduciary Breach for Assessing "Other Than Group Fees"; Insurer Requests Reconsideration of Ruling
  Pipefitters Local 636 Insurance Fund v. Blue Cross Blue Shield of Michigan
  
  
• Court rules that Insurance Commissioner Properly Disapproved Insurance Form Containing Improper Exclusion
  Blue Cross Blue Shield of Montana, Inc. v. Montana State Auditor
  
  
• Court Holds Insurers May Waive Anti-Assignment Provisions in ERISA Health Benefits Plans Through Conduct
  Glen Ridge SurgiCenter, LLC v. Horizon Blue Cross Blue Shield of New Jersey, Inc.
  
  
• Court rejects challenge to Kaiser arrangement involving charges to Third-Party Settlement because administrative remedies were not exhausted
  Glaus v. Kaiser Foundation Health Plan
  
  
• Court Holds that the Unilateral Activity of an Insured and Mere Forseeability are Not Sufficient to Establish Personal Jurisdiction for the Insurer
  Choice Healthcare Inc., et al. v. Kaiser Foundation Health Plan of Colorado, et al.
  
  
  
  

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September 2009 Managed Care Lawsuit Watch [full version]

• Court Dismisses Coverage Gap Allegations Against Independence Blue Cross
  Kopstein v. Independence Blue Cross
  
  
• Third Circuit Affirms Dismissal of Class Action Brought Against TRICARE Contractors
  Northern Michigan Hospitals, Inc., et al. v. Health Net Federal Services LLC
  
  
• Approval of AWP Settlements Upheld
  National Ass'n of Chain Drug Stores v. New England Carpenters Health Benefits Fund
  
  
• Court Holds that ERISA Does Not Preempt Claims Involving the Rate of Payment
  Lone Star OB/GYN Associates v. Aetna Health Inc.
  
  
• Federal Court Rules that Insurer Violated ERISA In Terminating Plan Participants' Coverage
  Merling v. Horizon Blue Cross Blue Shield of New Jersey
  
  
• State Appeals Court Upholds Federal Preemption Under ERISA for Claim Against Health Insurer That Enrollee's Provider Failed to Arrange For Medical Treatment
  Hulsman v. Behavioral Health Systems, Inc. and Blue Cross & Blue Shield of Alabama
  
  
• Third Circuit Reverses Trial Judge's Order Of Sanctions In Grider v. Keystone Health Plan
  Grider v. Keystone Health Plan Central, Inc.
  
  
  
  

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August 2009 Managed Care Lawsuit Watch [full version]

• Circuit Court Holds Reinstatement of Health Insurance Coverage Is ERISA Equitable Remedy
  Phelan v. Wyoming Associated Builders
  
  
• Ninth Circuit affirms dismissal of AlohaCare's breach of contract suit against Hawaii's Department of Human Services
  AlohaCare v. State of Hawaii, Department of Human Services, et al.
  
  
• OIG Issues Advisory Opinion Addressing Medigap Insurers' Use of "Preferred Hospital" Networks for Discounts for Policyholders
  Office of Inspector General Advisory Opinion 09-10
  
  
• Court Upholds Health Plan's Denial of Dental Procedures as Excluded Under Plaintiff's ERISA Plan
  Crosby v. BlueCross/Blue Shield of Louisiana
  
  
• Federal Court Rejects Plaintiff's Argument Against FEHBA Preemption of State Law Claim
  Barnes v. Humana, Inc. et al.
  
  
• Court Dismisses Infertility Coverage Claim Against Blue Cross of California
  Yeager v. Blue Cross of California
  
  
  
  

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July 2009 Managed Care Lawsuit Watch [full version]

• FTC Proposes Settlement in Price-Fixing Case Against Independent Practice Association
  In re Alta Bates Medical Group, Inc.
  
  
• Court Permits Employer to Replead Breach of Contract Claim as ERISA Claim
  G.R.J.H. Inc. v. Oxford Health Plans Inc.
  
  
• Court Holds that Patient Consent Forms Supersede Doctor-Patient Privilege
  Medical Mutual of Ohio v. Schlotterer
  
  
• Tenth Circuit Rules that Reimbursement Claims are Subject to the PBM's Arbitration Clause But Unfair Business Practice Claims are Not Subject to Arbitration
  Chelsea Family Pharmacy, PLLC v. Medco Health Solutions, Inc.
  
  
• District Court Permits Suit Against CMS Alleging the Agency Improperly Approved Hawaii's Medicaid Managed Care Program Contracts
  G., Parent and Next Friend of K., a Disabled Child, et al. v. State of Hawai'i Dept. of Human Serv., et al.
  G., Parent and Next Friend of K., a Disabled Child, et al. v. United States Dept. of Health and Human Serv., et al.
  
  
• ERISA Does Not Preempt A Patient's Claim of Negligent Misrepresentation of Benefits by Treating Physician
  Thompson v. TransAm Trucking, Inc. et al.
  
  
• Eastern District of Michigan Dismisses ERISA Claims For Alleged Breach of General Motors Plan
  John L. Hill, Francine Barnes, and Glory Celestine, v. Blue Cross and Blue Shield of Michigan
  
  
• ERISA Preempts D.C. Law Regarding PBMs
  Pharm. Care Mgmt Ass'n v. D.C.
  
  
• Court Dismisses Civil Conspiracy, Fraud, and Other Claims against Health Insurers
  Blue Springs Internal Medicine, P.C. v. Blue Cross and Blue Shield of Kansas City
  
  
• Court Denies Class Action Status for Autism Benefits Dispute
  Johns v. Blue Cross Blue Shield of Michigan
  
  

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March 2009 Managed Care Lawsuit Watch [full version]

• Remaining Blue Cross Blue Shield Defendants Win Dismissal Ruling in In re Managed Care MDL
  Love v. Blue Cross and Blue Shield of Arizona, Inc.
  
  
• District Court Dismisses Insured's Claims as Preempted by Medicare Law Since Insured Must First Meet Presentment and Exhaustion Requirements
  Kaye v. Humana Ins. Co.
  
  
• Texas Attorney General and Memorial Hermann Healthcare System Settle Restraint of Trade Case
  State of Texas v. Hermann Healthcare System
  
  
• FTC Approves Final Consent Order with IPA Accused of Price-Fixing
  Independent Practice Associates Medical Group, Inc., d/b/a AllCare IPA
  
  
• Northern District of Illinois Throws Out Antitrust and Fraud Claims Against UnitedHealth Group, PacifiCare and RxSolutions
  Omnicare, Inc. v. UnitedHealth Group, Inc.
  
  
• California Supreme Court Rules that Knox-Keene Act Prohibits Balance Billing for Emergency Services
  Prospect Medical Group, Inc. v. Northridge Emergency Medical Group
  
  
• Court Reaffirms Decision that State Health Plan Procurement Law is Unconstitutional Under the Dormant Commerce Clause
  United HealthCare Insurance v. Honorable Kathleen Blanco Consolidated with Humana Insurance Company and Humana Health Benefit Plan of Louisiana, Inc. v. Jerry Luke LeBlanc, et. al.
  
  
• Court Enters Summary Judgment for Dental HMO Holding that Class Representative Failed to Exhaust Administrative Remedies
  Kaden v. First Commonwealth Insurance Company
  
  

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January 2009 Managed Care Lawsuit Watch [full version]

• Appeals Court Affirms the Dismissal of Insurance Agency's Inadequately Pled Complaint Regarding Anti-Competitive Behavior
  Total Benefits Planning Agency, Inc. v. Anthem Blue Cross and Blue Shield
  
  
• State Court Holds that Medicare Act Preempts "Intertwined" State Law Claims
  Edwards v. Blue Cross Blue Shield of Texas
  
  
• Federal Court Rules Failure to Comply with a Broad Certification Does Not Support False Claims Act Qui Tam Complaint Against Pharmacy Benefit Manager
  United States ex rel. Lobel v. Express Scripts Inc.
  
  
• FEHBA Not Implicated in Coverage Denial Dispute between Provider and Insurer
  Francesco v. Group Health Inc.
  
  
• Health Plan Not Required to Pay Medical Fees Where Deceased Failed to Extend Coverage Before Plan Termination
  Estate of John Cecil Spinner, Deceased v. Anthem Health Plans of Virginia, et al.
  
  
• Retired Workers Entitled to Notice Under COBRA Despite Receiving Alternate Health Benefits under Retirement Package
  Carolyn C. Phillips, et al., v. Wythe County Community Hospital, et al.
  
  
  

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December 2008 Managed Care Lawsuit Watch [full version]

• Federal Court Grants Preliminary Approval of United Healthcare Class Action Settlement
  Am. Med. Ass'n v. United Healthcare Corp.
  
  
• Court Rules that Settlement Proceeds Are Not Plan Assets and Plan Member is Not a Fiduciary
  Health First Health Plans Inc. v. Glatter
  
  
• Federal Court Denies Class Certification, Grants Plaintiff Partial Summary Judgment
  Smith v. Life Investors Insurance Co. of America
  
  
• Court Remands Subrogation Case, Finds No Federal ERISA Preemption
  Cottrill v. Allstate Ins. Co.
  
  
• Court Finds California Health and Safety Code's HMO Standards Federally Preempted When Applied to a Medicare Advantage HMO
  Yarick v. Pacificare of California
  
  
• Claims Against Insurer for Cancellation of Coverage are Preempted by ERISA
  Grandcolas v. Healthy Alliance Life Ins. Co et al
  
  
• Maryland Court of Appeals Holds Coordination of Benefits in Policies Not Restricted
  MAMSI Life & Health Ins. Co. v. Wu
  
  
  

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November 2008 Managed Care Lawsuit Watch [full version]

• Ninth Circuit Holds ERISA Does Not Preempt San Francisco's Law Requiring Employers to Fund Health Care for Employees.
  Golden Gate Rest. Ass'n v. City and County of San Francisco
  
  
• Court Dismisses Provider Lawsuit Alleging Insurer Payments Violated ERISA.
  Riverview Health Institute LLC v. Med. Mutual of Ohio
  
  
• Federal Court Dismisses Complaint Against Health Insurer and Requires Parties to Arbitrate as Ordered by State Court.
  Jamaica Hospital Medical Center v. UnitedHealth Group, Inc., et. al.
  
  
• Court Dismisses False Claims Act Qui Tam Complaint.
  United States of America ex re. Bonnie Sterling v. Health Insurance Plan of Greater New York
  
  
• Court Rules State Law Claims Not Preempted by ERISA.
  Omega Hosp. v. Aetna Life Ins. Co.
  
  
• Health Plans Cannot Bring Joint Claims or Class Action Against Vioxx Settlement Program Administrator.
  In Re: Vioxx : Products' Liability Litigation
  
  
• Lawsuit to Proceed against Blue Cross Blue Shield of Michigan concerning Acquisitions of Workers Compensation Insurers.
  Attorney General Mike Cox v. Blue Cross Blue Shield of Michigan
  
  
• Court Denies Health Plans' Request for Production of City's Documents.
  New York City v. Group Health, Inc.
  
  
  

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September 2008 Managed Care Lawsuit Watch [full version]

• WellCare Pays $35.2 Million for Understatements of Anticipated Premium Refunds.
  WellCare Agreement
  
  
• Amerigroup Corp. to Settle Whistleblower Litigation for $334 Million.
  United States ex rel. Tyson v. Amerigroup Illinois Inc.
  
  
• Missouri Court Reverses Denial of Insurers' Motions to Compel Arbitration.
  Kansas City Urology et al. v. United Healthcare Services et al.
  
  
• Federal Court Dismisses Class Action Antitrust Suit Against Drug Wholesaler.
  New England Carpenters Health Benefits Fund v. McKesson Corporation
  
  
• Tenth Circuit Upholds Jury Verdict Awarding Insured $1.1 Million For Insurance Fraud.
  Cook v. Medical Savings Insurance Co.
  
  
• The Western District Court of North Carolina permits an antitrust action against Blue Cross and Blue Shield of North Carolina to proceed for monopolistic conduct in the purchase of health care provider services.
  Dr. John Powderly II & Carolina Biooncology Institute, PLLC v. Blue Cross and Blue Shield of North Carolina
  
  
• District Court Dismisses Cardiologists' Sherman Act and Clayton Claims With Prejudice.
  Little Rock Cardiology Clinic, P.A. v. Baptist Health, et al.
  
  

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July 2008 Managed Care Lawsuit Watch [full version]

• Supreme Court Limits Deference to Claim Denials by Fiduciaries with Conflict of Interest.
  Metropolitan Life Ins. Co. v. Glenn
  
  
• Supreme Court Holds that False Claims Act Requires Proof of Intent to Defraud Government.
  Allison Engine Co. v. United States ex rel. Sanders
  
  
• Court Holds that Hospitals Must Exhaust Administrative Remedies under TriCare program.
  Northern Michigan Hospitals, Inc. and Gifford Medical Center, Inc. v. Health Net Federal Services, LLC and Lakewood Health System and Northwest Medical Center v. Triwest Healthcare Alliance Corp.
  
  
• Florida District Court Dismisses Provider Class Action RICO Complaint.
  Solomon v. Blue Cross and Blue Shield Association, et. al.
  
  
• Federal District Court Certifies Class of Pharmacies Despite Large Disparity in Potential Damages.
  Eufaula Drugs Inc. v. TDI Managed Care Svcs. Inc.
  
  
• Court Approval Sought in Part D Settlement.
  Situ v. Leavitt
  
  
• Aetna Reaches Settlement in Class Action Suit.
  DeVito v. Aetna, Inc.
  
  
• Appeals Court Vacates Class Certification Order in Suit Involving Denial of Benefits.
  Doiron v. Conseco Health Insurance Co.
  
  
• Federal District Court Grants Summary in Favor of Insurers in Reimbursement Case.
  Cooper v. Premera Blue Cross, et. al.
  
  
• Manufacturers' Claim Against PBM and Insurer Dismissed.
  Hill Dermaceuticals, Inc. v. RX Solutions, United Health Group, Inc. and United Healthcare of Florida, Inc.
  
  
• Wisconsin Supreme Court Orders Health Insurer to Retroactively Reinstate Cancer Treatment Benefits.
  Summers v. Touchpoint Health Plan, Inc.
  
  
  

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June 2008 Managed Care Lawsuit Watch [full version]

• Appellate court affirms lower court decision awarding provider $1.5 million in withheld payments.
  Health Options Inc. v. Palmetto Pathology Services, PA
  
  
• Ninth Circuit Holds No Violation of Sherman Act by Health System and Health Plan.
  East Portland Imaging Center, PC v. Providence Health System-Oregon, et. al.
  
  
• Illinois Managed Care Organizations Can Pay Non-Network Providers an Amount Set by the State.
  Midwest Emergency Associates-Elgin Ltd., v. Harmony Health Plan Of Illinois, Inc.
  
  
• California Department of Managed Health Care Settlement Disputes with Health Plan on Coverage Recision.
  California Department of Managed Health Care Settlements
  
  
  

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May 2008 Managed Care Lawsuit Watch [full version]

• Federal court approves settlement in class action suit against Blue Cross and Blue Shield Plans and Association.
  Love v. Blue Cross and Blue Shield Association
  
  
• Sixth Circuit Affirms Dismissal of M+C Plan Enrollee's Claims for Reimbursement.
  Giesse v. Sec. of the Dept. of Health & Human Serv's
  
  
• FTC Issues Final Order on Remedy in Evanston Hospital Merger.
  In re Evanston Northwestern Healthcare Corp.
  
  
• Two Connecticut Chiropractic Trade Associations and its Attorney Settle with FTC for Alleged Anti-Competitive Conduct.
  In the Matter of: The Connecticut Chiropractic Association et al.
  
  
• Arbitration Provision Held Unenforceable.
  Raudel Rodriguez v. Blue Cross of California, et al.
  
  
• Federal Court Rules on Incorrect Withholding of Part D Premiums by CMS and SSA.
  Mercado v. Leavitt
  
  
• Federal Court Conditionally Approves Non-Par Claims Settlement.
  Stewart Scharfman, Zev and Linda Wachtel and Renee McCoy v. Health Net
  
  
• Michigan Insurance Commissioner May Consider, but is not Required to Follow Independent Review Organization's Recommendations.
  Ross v. Blue Care Network of Michigan
  
  
• Sixth Circuit Affirms Ruling that Exclusive Network of Preferred DME Providers Does Not Violate Antitrust Laws.
  B & H Medical, L.L.C. v. ABP Admin., Inc.
  
  

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February 2008 Managed Care Lawsuit Watch [full version]

• Eighth Circuit Determines Health Plan Employee Is Potentially Individually Liable for Network Provider's Claims of Underpayment.
  Hohn v. Surgeon
  
  
• Health Plans Win Damage Rulings in First Indirect Purchaser Pharmaceutical Antitrust Case Tried to Verdict.
  In re Lorazepam & Clorazepate Antitrust Litigation
  
  
• Health Plan Sues Physician for Billing Fraud, But Physician Not Required to Disclose Billing Information Because of Physician-Patient Privilege.
  Medical Mutual of Ohio v. Schlotterer
  
  
• Illinois Insurance Division Fines Humana, Inc. For Using Unlicensed Agents for Medicare Advantage Coverage.
  In the Matter of Humana Insurance Company
  
  
• California Court of Appeal Denies Blue Shield's Motion for Rehearing in Post-Claims Underwriting Challenge.
  Hailey v. California Physicians' Service d/b/a/ Blue Shield of California
  
  
• Federal Court Finds Medicare Advantage Preemption Provision Does Not Constitute "Complete Preemption" and Does Not Give Rise to Federal Jurisdiction.
  Williams v. Viva Health Inc.
  
  
• Federal Court Finds Medicare Advantage Preemption Provision Preempts California Statute, Compels Arbitration.
  Clay v. Permanente
  
  
• Federal Court Finds Medicare Advantage Preemption Provision Preempts California Statute, Compels Arbitration - Again.
  Drissi, et al. v. Kaiser Foundation Hospitals, Inc., et al.
  
  
• Eleventh Circuit Allows Plan To Seek Reimbursement Directly From Third-Party Conservator of Special Needs Trust.
  Admin. Comm. for the Wal-Mart Stores, Inc. Assocs.' Health and Welfare Plan v. Horton, et al.
  
  
• Federal District Court Says Wal-Mart's Employee Benefit Plan Can Refuse to Provide Benefits If Employee Refuses to Sign Subrogation Agreement.
  Cossey v. Associates' Health and Welfare Plan
  
  
• Ninth Circuit Allows San Francisco Health Ordinance to Proceed, For Now.
  Golden State Restaurant Association v. San Francisco
  
  
• Connecticut Supreme Court Upholds Health Plan's Termination of Participating Physician.
  Ramirez v. Health Net of the Northeast, Inc.
  
  
• District of New Jersey Dismisses ERISA Claims Against Health Insurers.
  In re Insurance Brokerage Antitrust Litigation
  
  
• ERISA Does Not Preempt Coverage of Residential Care Provided for By Mandated Benefits Statute.
  Wedekind, et al., v. United Behavioral Health and United Healthcare Insurance Co.
  
  
• Ninth Circuit Affirms Judgment that Vision Service Plan Is Not Tax Exempt.
  Vision Service Plan, Inc. v. U.S.
  
  
• United HealthGroup's PacifiCare Subsidiaries Fined $3.5 Million for Alleged Claims-Handling Violations.
  Report of the Market Conduct Examination of the Claims Practices of the PacifiCare Life & Health Insurance Co.
  
  

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January 2008 Managed Care Lawsuit Watch [full version]

• EEOC Final Rule Allows Employers to Reduce or Eliminate Retiree Benefits for Medicare-Eligible Retirees.
  U.S. Equal Employment Opportunity Commission; Age Discrimination in Employment Act; Retiree Health Benefits: Final Rule
  
  
• Pharmacy Benefits Manager Is Not An ERISA Fiduciary, According to Court.
  Moecke v. Caremark, Inc.
  
  
• Health Plans Must Demonstrate Misrepresentation or Willful Omission Before Rescinding Coverage.
  Hailey v. California Physicians' Service, d/b/a Blue Shield of California
  
  
• No Private Right of Action Under Nevada Prompt Pay Statute.
  Allstate Insurance Co. v. Thorpe
  
  
• ERISA Preempts City Ordinance Mandating Employer Health Care Expenditures.
  Golden Gate Restaurant Association v. City and County of San Francisco
  
  
• U.S. Court Invalidates Plan's Attempt to Terminate Vested Benefits.
  Halbach. v. Great-West Life & Annuity Ins. Co.
  
  
• Commissioner of California Department of Insurance Will Seek $12.6 Million in Fines Against Blue Shield of California.
  Report of the Market Conduct Examination of the Claims Practices of Blue Shield of California Life & Health Insurance Company
  
  
• Plan Properly Denied Coverage of Costs of Treating Complications Resulting from "Tummy-Tuck" Procedure.
  Dillon v. Anthem Health Plans of Virginia, Inc.
  
  

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June 2007 Managed Care Lawsuit Watch [full version]

• District Court Dismisses Claims Asserted by Medicare Beneficiary and Third Party Payers for Lack of Standing in ICD Litigation against Guidant.
  In re Guidant Corp. Implantable Defibrillators Products Liability Litigation
  
  
• District Court Refuses to Compel Production of Cost and Experience Information in Health Plan Merger Lawsuit.
  City of New York v. Group Health Inc.
  
  
• Medicare Advantage Plan May Not Compel Arbitration Of Member's Heir's Claims.
  Martin et al v. Pacificare of California, et al.
  
  
• Federal Court Denies Plaintiffs' Motion For Remand of Claims Challenging Health Plan's Subrogation Clause, and Grants Defendants' Motion to Dismiss.
  White v. Humana Health Plan Inc.
  
  
• Florida Jury Awards Pathology Laboratory $1.5 Million Against HMO for Unpaid Professional Services.
  Palmetto Pathology Servs. v. Health Options, Inc.
  
  
• Court Denies Hospitals' Claims For Misrepresentation and Deceptive Trade Practices Against Employee Benefits Fund And Third-Party Administrator.
  Roofers Local No. 20 Health and Welfare Fund v. Memorial Hermann Hospital System, et al., v. FMH Benefit Services, Inc.
  
  
• Texas State Appellate Court Rules in Favor of Medicaid HMO; Payment Unnecessary When Medicaid Eligibility Changes.
  Methodist Hospitals of Dallas v. Amerigroup Texas, Inc.
  
  
• Failure to Inform Employee of Enrollment Denial Results in Employer's Breach of ERISA Fiduciary Duty.
  Hansen v. Harper Excavating, Inc.
  
  
• ERISA Preempts Member's State Law Claims Arising From Denial Of Coverage For Inpatient Rehabilitation Services.
  Kinnison v. Humana Health Plan of Texas, Inc., et al.
  
  
• Federal District Court Holds That ERISA Does Not Preempt Plan Participant's Medical Negligence Claims.
  Badal v. Hinsdale Memorial Hosp.
  
  
• State Law Claims Based on Prior Approval or Misrepresentation not Subject to ERISA Preemption.
  Center for Restorative Breast Surgery, LLC v. Blue Cross Blue Shield of Louisiana
  
  
• Court Denies Insurer's Motion Requesting MRI Provider to Produce Witness.
  Elmont Open MRI v. New York Central Mutual Fire Insurance Co.
  
  
• UnitedHealthcare to Pay $650,000 to Settle Allegations of Violations of Nebraska Insurance Code.
  State of Nebraska v. United Healthcare Group, et al.
  
  

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May 2007 Managed Care Lawsuit Watch [full version]

• Blue Cross and Blue Shield plans and the Blue Cross and Blue Shield Association to Pay $128 Million To Settle Class Action Suit.
  Love v. Blue Cross & Blue Shield Association
  
  
• Court of Federal Claims Declares OPM Regulation Arbitrary.
  GHS HMO, Inc. v. U.S.
  
  
• New Hampshire Law Prohibiting Sale of Provider-Identified Prescription Data Violates First Amendment.
  IMS Health Inc. v. Ayotte
  
  
• District Court Finds ERISA Does Not Preempt Lawsuit Brought By 21 Hospitals Against Health Plan.
  Barnert Hospital v. Horizon Healthcare Services, Inc., d/b/a Horizon Blue Cross Blue Shield of New Jersey
  
  
• District Court Finds OPM Coverage Determination To Be Arbitrary and Capricious.
  Dunn v. Office of Personnel Management
  
  
• Subsidiary of Pfizer Pleads Guilty to Federal Health Care Program Anti-Kickback Statute, Will Be Permanently Excluded from Federal Health Care Programs.
  U.S. v. Pharmacia and Upjohn Company, Inc.
  
  
• Court Holds that New York Attorney General Properly Stated Claims For Fraud and Bid Rigging.
  New York ex rel. Spitzer v. Liberty Mutual Holding Co., Inc., et al.
  
  
• Adoptive Parents' Health Plan Liable for Adopted Child's Medical Care.
  Quaid v. U.S. Healthcare Inc.
  
  
• Blue Cross Blue Shield of Nebraska Reasonably Limited Patient's Claims for Drugs.
  Brooks v. Nebraska By-Products, Inc., and Blue Cross Blue Shield of Nebraska
  
  
• ERISA Does Not Preempt HMO's Claim Against Employer of Ineligible Worker.
  Carolina Care Plan, Inc. v. Auddie Brown Auto Sales of Florence Inc.
  
  
• Physician's Promissory Estoppel Claim Against Insurer and Cost Management Company for Allegedly Providing Incorrect Coverage Information Survives Summary Judgment.
  Crawford v. Central State, Southeast and Southwest Areas Health and Welfare and Pension Funds
  
  
• Court Rules That Automobile Liability Insurer Has Standing Under ERISA To Challenge Whether Employer-Sponsored Plan Is Primary To A Coordinated No-Fault Policy.
  State Farm Mut. Auto. Ins. Co. v. Washington Group Int'l, Inc.
  
  
• Aetna's Denial of Benefits to Allegedly Fully Handicapped Dependent Does Not Violate Tennessee State Law.
  Williamson v. Aetna Life Ins. Co.
  
  
• Federal Court Holds that Coverage of Nursing Home Facilities Does Not Include Coverage of Assisted Living Facilities.
  Michel v. American Family Life Assurance Co.
  
  
• California District Court Finds ERISA Does Not Preempt Premature Death Lawsuit.
  Wells v. California Physicians' Service, d/b/a Blue Shield of California
  
  
• California Court of Appeal Rejects Antitrust Challenge To Physical Therapy Group's Preferred Provider Status With Blue Cross of California.
  Lori Rubinstein Physical Therapy, Inc. v. PTPN, Inc., et al.
  

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April 2007 Managed Care Lawsuit Watch [full version]

• Third Circuit Court of Appeals Overrules District Court, Finds Attorney Client Privilege Does Apply to Health Insurer's Communications with Outside Counsel.
  Wachtel v. Health Net, Inc.
  
  
• $334 Million Awarded against Medicaid HMO in Qui Tam False Claims Act Case.
  U.S. ex rel. Tyson v. Amerigroup Illinois, Inc., et al.
  
  
• Court Declines To Set Default Rate Under "Reasonable And Necessary Costs" Provision In Statute Requiring Reimbursement To Out-of-Network Providers.
  Trustees of the University of Pennsylvania Health System d/b/a University of Pennsylvania Health System, et al., v. Americhoice of Pennsylvania
  
  
• Third Circuit Court of Appeals Allows Physician's Class Action Suit Alleging Downcoding and Code Bundling to Proceed Against Oxford Health Plans.
  Sutter v. Oxford Health Plans LLC
  
  
• California Court Refuses to Enforce Arbitration Provision in Subscriber Contract.
  Ogle v. PacifiCare Life and Health Ins. Co.
  
  
• Court Holds That Pharmaceutical Care Management Association Is Collaterally Estopped From Challenging D.C. Disclosure Law.
  Pharmaceutical Care Mgmt. Assoc. v. District of Columbia
  
  
• Third Circuit Holds that ERISA Preempts Plaintiff's Claim that Health Plan was Untimely in Granting Preauthorization.
  Kurtek v. Capital Blue Cross
  
  
• Blue Cross of California Fined $1 Million for Alleged Wrongful Post-Claims Underwriting.
  Non-Routine Medical Survey of Blue Cross of California, a Full Service Health Plan
  
  
• Discovery Disputes Continue in Antitrust Lawsuit by Specialty Hospital against Competitor and Insurer; Hospital Association Not Required to Produce Documents Related to Legislative Activities
  Heartland Surgical Specialty Hosp. v. Midwest Div. Inc.
  

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March 2007 Managed Care Lawsuit Watch [full version]

• Court Finds Plan Waived Attorney-Client Privilege by Referring to Attorney Advice in Contract Negotiations.
  Heartland Surgical Specialty Hosp. v. Midwest Div. Inc.
  
  
• Managed Care Company Agrees to Pay $975,000 in Civil Settlement to Resolve Allegations that it Overcharged FEHBP.
  U.S. ex rel. Esktrand v. WellPoint Health Networks, Inc.
  
  
• Eighth Circuit Rules that the Policy Constitutes a Plan Document and Plan Administrator's Benefit Denial is Reviewable Under the ERISA Abuse of Discretion Standard.
  Rittenhouse v. UnitedHealth Group Long Term Disability Ins. Plan
  
  
• Florida's HMO Act Does Not Provide A Private Right of Action.
  Electrostim Medical Services Inc. v. Aetna Life Insurance Co.
  
  
• Federal Court Grants Preliminary Approval to $24 Million Settlement Of Class Action That Alleged Fraudulent Practices Involving AIDS Drug Serostim.
  Gov't Employees Hosp. Assn., et al., v. Serono Int'l., S.A., et al.
  • Francis v. Serono Lab., et al.
    
• Absence Of Individual Loss Does Not Deny A Beneficiary Standing To Bring A Breach Of Fiduciary Duty Claim On Behalf Of His Plan.
  Deluca v. Blue Cross Blue Shield of Michigan
  
  
• District Court Holds That Claims of Misrepresentation of Coverage Were Barred by Statute of Limitations and Preempted by ERISA.
  Ambulatory Infusion Therapy Specialists, Inc., v. Aetna Life Ins. Co.
  
  
• Arbitration Agreement Extends to Provider's Claims Asserted Under Louisiana's "Any Willing Provider" Statute.
  CorVel Corp. v. Southwest La. Hosp. Assoc. d/b/a Lake Charles Memorial Hosp.
  
  
• Benefit Plan Did Not Abuse Discretion in Reducing Amount Paid to Hospital.
  Catholic Healthcare West-Bay Area v. Seafarers Health and Benefits Plan
  
  
• Federal District Court Refuses to Apply Class Action Fairness Act and Allow Removal of Class Action to Federal Court.
  Eavenson v. Selective Insurance Co. of America
  

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February 2007 Managed Care Lawsuit Watch [full version]

• Seventh Circuit Finds Pharmacy Benefit Management Company Did Not Act As Plan Fiduciary And Did Not Breach ERISA Fiduciary Duties.
  Chicago District Council of Carpenters Welfare Fund v. Caremark Inc.
  
  
• Federal District Court Allows Provider, Beneficiary, and Medical Association Plaintiffs to Add Antitrust and RICO Claims to Suit Against Insurer.
  The American Medical Association, et al. v. United Healthcare Corporation
  
  
• Federal Court Rejects Insurers' Arguments to Remove Medical Provider's Lawsuit to Federal Court on ERISA Grounds, Remands Case to State Court.
  Riverside Medical Associates v. Humana, Inc.
  
  
• U.S. District Court Holds ERISA Completely Preempts Claims Under Texas "Any Willing Provider" Law.
  Quality Infusion Care, Inc. v. Aetna Health, Inc.
  
  
• District Court Upholds Louisiana Law Prohibiting Subrogation Until Plan Participant Is Made Whole.
  Benefit Recovery, Inc. v. Wooley
  
  
• Health Plan Administrator Found Not Liable For Hospital's Costs of Treatment Incurred On Basis Of Plan's Alleged Coverage Misrepresentations.
  St. Luke's Episcopal Hospital v. Principal Life Insurance Co.
  
  
• Dentists' State Law Claims of Insurer's Fraudulent Billing Practices Preempted by ERISA and FEHBA.
  Alabama Dental Ass'n v. Blue Cross and Blue Shield of Alabama, Inc.
  
  
• Federal Court Rules that ERISA Does Not Preempt Hospital's Breach of Contract And Misrepresentation Claims Against Benefits Plans.
  Fresno Comm. Hosp. and Med. Ctr. v. UFCW Employers Benefit Plan of N. Cal. Group Admin., et al.
  
  
• District Court Rejects Class Certification to Insurance Agents Allegedly Instructed to Deny Medicare Coverage.
  Justice v. Physicians Mutual Insurance Co.
  
  
• District Court Requires Plan To Disclose Its Claims Administrator's Internal Guidelines.
  Mondry v. American Family Mutual Insurance Co.
  
  
• Plan's Denial of Benefits Under A 24-Month Limitation On Mental Disorder-Related Disabilities Was Not Arbitrary and Capricious.
  Randles v. The Galichia Med. Group, P.A. ERISA Benefit Plan
  
  
• Court Finds Hospital Cannot Bring ERISA Breach of Fiduciary Duty As Assignee of Benefits.
  Via Christi Regional Medical Center, Inc. v. Blue Cross and Blue Shield of Kansas, Inc.
  
  
• Health Plan Administrator and Case Management Vendor May Have Fraudulently Induced Out-Of-Network Hospital to Render Services to Plan Beneficiary, Knowing Plan Did Not Cover Services.
  Regency Hospital Co. of Meridian, LLC v. Gilsbar, Inc., et al.
  

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January 2007 Managed Care Lawsuit Watch [full version]

• Fourth Circuit Affirms ERISA Preemption of Maryland's "Wal-Mart" Health Care Statute.
  Retail Industry Leaders Association v. Fielder
  
  
• Connecticut State Court Upholds State Agency Decision Entitling Access to Insurers' Medicaid Managed Care Documents.
  Health Net of Connecticut v. Freedom of Information Commission, et al.
  
  
• Tennessee Court Rules That Agreement Between Physicians And Blue Cross Compels Arbitration Of Claims.
  Rosenberg v. Blue Cross Blue Shield of Tenn.
  
  
• California State Court Declines to Enforce Arbitration Provision in HMO Agreement Because Provision Was Not Prominently Displayed On Enrollment Form.
  Zembsch v. The Superior Court of Alameda County
  
  
• South Carolina State Appeals Court Rules that Medical Device Designed to Treat Misshaped Skull is Within Scope of Coverage.
  James v. State of South Carolina Employee Insurance Program
  
  
• United Healthcare of New York Settles New York Attorney General's Allegations of Network Billing Errors.
  In the Matter of United Healthcare Insurance Company of New York
  

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December 2006 Managed Care Lawsuit Watch [full version]

• Missouri State Court Finds Arbitration Clauses Unconscionable and Void As Against Public Policy, Allows Physicians' Class Action Antitrust Conspiracy Claims to Continue.
  Kansas City Urology Care, P.A., et al., v. Blue Cross and Blue Shield of Kansas City, Inc., et al.
  
  
• Class Action Suit Allowed to Proceed With Claim That Insurer Improperly Maintained Excess Reserves.
  Ciamaichelo v. Independence Blue Cross
  
  
• Multiemployer Health Fund's ERISA Cause of Action Seeking Refund of Overpayment Dismissed, Not Seen As "Equitable".
  Vacca v. Trinitas Hospital
  
  
• ERISA Preempts Missouri Prompt Payment Act.
  Schoedinger v. United Healthcare of the Midwest Inc.
  
  
• Supreme Court Declines to Review Blue Cross & Blue Shield Petition in RICO Case.
  Blue Cross & Blue Shield of Michigan v. Genord
  
  
• Supreme Court Declines to Review Georgia Holding That ERISA Preempts Claims Against Pharmacy Benefit Manager.
  Bauer et al. v. AdvancePCS, et al.
  
  
• Federal District Court Finds That Settlement in Pharmaceuticals Drug Price Case is Fair.
  New England Carpenters Health Benefits Fund v. First Databank, Inc.
  
  
• Third Circuit Holds That HMOs Are Exempt from State Anti-Subrogation Law.
  Wirth v. Aetna US Healthcare
  
  
• District Court Upholds Denial of Benefits Based on Health Plan's "Surrogate Mother" Exclusion.
  Florida Health Science Center Inc. v. Rock
  

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November 2006 Managed Care Lawsuit Watch [full version]

• Florida Supreme Court Allows Providers to Sue HMOs for Prompt Payment.
  Foundation Health v. Westside EKG Associates
  
  
• Hawaii Supreme Court Reinstates Unfair Trade Practices Act Lawsuits Against Insurer.
  Hawaii Medical Ass'n v. Hawaii Medical Service Ass'n Inc.
  
  
• Tenth Circuit Holds Health Plan Did Not Violate Sherman Act By Providing Eye Care Through Panel of Ophthalmologists.
  Abraham v. Intermountain Health Care Inc.
  
  
• Pennsylvania Supreme Court Holds State Anti-Subrogation Statute Does Not Apply to HMOs.
  Wirth v. Aetna U.S. Healthcare
  
  
• Providers Have an Implied Right of Action Under Florida Statutory Law to Assert Underpayment Claims Against HMOs.
  Merkle v. Health Options
  
  
• Jury Finds Medicaid HMO Violated False Claims Act; Damages Could Equal $144 Million.
  U.S. ex rel. Cleveland Tyson v. Amerigroup Illinois, Inc.
  
  
• Federal District Court Determines It Lacks Subject Matter Jurisdiction to Hear ERISA Case.
  Newark Beth Israel v. Northern New Jersey Teamsters Benefit Plan
  
  
• Ohio Federal District Court Refuses to Dismiss Lawsuit Alleging Insurance Companies' Improper Refusal to Deal.
  Total Benefits Planning Agency Inc., et al., v. Anthem Blue Cross and Blue Shield, et al.
  
  
• Fifth Circuit Holds That Company Violated Plan Requirements by Modifying Retirees' Benefits Without Making Similar Modifications to Active Employees' Benefits.
  Halliburton Co. Benefits Comm. v. Graves
  
  
• Texas District Court Determines that Texas Law – Not ERISA – Governs Out-Of-Network Pharmacy's Claims to Payment.
  Quality Infusion Care Inc. v. Unicare Health Plans of Texas, Inc.
  
  
• Texas State Court Determines That Infusion Therapy Provider Is Not A Network Provider, Refuses To Order Payment.
  Quality Infusion Care Inc. v. Health Care Service Corp. d/b/a Blue Cross and Blue Shield of Texas
  
  
• Illinois Supreme Court Finds Percentage-Based Arrangements Violate Fee-Splitting Prohibition.
  Vine Street Clinic v. HealthLink Inc.
  
  
• Washington State Court Says Health Plan Did Not Act In Bad Faith When It Refused to Cover An Out-of-State Procedure That Was Locally Available.
  Hunter v. Regence Blue Shield
  
  
• 4th Circuit Says Plan's Denial of Coverage of Cochlear Implant Is Unreasonable.
  Carolina Care Plan Inc. v. McKenzie
  

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September/October 2006 Managed Care Lawsuit Watch [full version]

• D.C. Appellate Court Rejects "Make Whole" Subrogation Rule.
  Moore v. CapitalCare, Inc.
  
  
• Mississippi Supreme Court Allows Beneficiary to Proceed With Tort Claims Against Insurer for Disclosure of Confidential Information.
  Robley v. BlueCross and BlueShield of Mississippi
  
  
• 5th Circuit Says ERISA Does Not Preempt Louisiana Assignment of Benefits Statute.
  Louisiana Health Service & Indemnity, Co. v. Rapides Healthcare System
  
  
• Ohio Court: If Provider's Claims Sound In Tort or Statute, ERISA Does Not Preempt Them.
  Miami Valley Hospital v. Community Insurance Co., d/b/a Anthem Blue Cross & Blue Shield
  
  
• 2nd Circuit Says M+C Appeal Process Not the Proper Forum for Claims Akin to Medical Malpractice.
  Matthews v. Leavitt
  
  
• Washington Supreme Court Invalidates Insurer's Arbitration Clauses.
  Kruger Clinic Orthopaedics v. Regence BlueShield
  
  
• FTC and IPAs Settle Charges that IPAs' Insistence On Risk Contracting Violates FTC Act.
  In re New Century Health Quality Alliance Inc.
  
  
• Court Okays Blue Cross of California's New Payment Policy for Endoscopic Procedures.
  California Hospital Assn. v. Blue Cross of California
  

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July/August 2006 Managed Care Lawsuit Watch [full version]

• Supreme Court Says FEHBA Does Not Provide Federal Jurisdiction For Subrogation Claims.
  Empire HealthChoice Assurance Inc. d/b/a Empire Blue Cross Blue Shield v. McVeigh
  
  
• Cruz v. Blue Cross Blue Shield of Illinois
  
  
• Physicians' Class Action Attack On Against Managed Care Dismissed.
  In re: Managed Care Litigation
  
  
• Second Circuit Says Downcoding Is Okay, If In Response To Upcoding.
  Sewell v. 1199 National Benefit Fund for Health and Human Services
  
  
• District Court Construes Coverage Provisions Broadly, Allows Custodial Care.
  Murch v. Prudential Welfare Benefits Plan
  
  
• ERISA Not A Bar To Equitable Claims, But Statute of Limitations Is.
  Syndicated Office Systems, Inc. v. Guardian Life Ins. Co.
  
  
• Court Sides With Auto Insurer In Coordination of Benefit Case.
  Citizens Ins. Co. of America v. MidMichigan Health ConnectCare Network Plan
  
  
• Pharmacies' Damages Action Against PBMs Allowed to Proceed.
  Beeman et al. v. TDI Managed Care Services, Inc. d/b/a Eckerd Health Services
  
  
• Insurer's Poor Handling Of Subscriber's Claims Results In Verdict of Health Care Fraud, $550,000 In Damages.
  Cook v. Medical Savings Insurance Co.
  
  
• Michigan Appellate Court Affirms Trial Court, Upholds Reversal of IRO Decision.
  Ross v. Blue Care Network of Michigan
  
  
• California Court Says Health Plans May Share Patient Records With Attorneys.
  California Consumer Health Care Council v. Kaiser Foundation Health Plan, Inc.
  
  
• Court Finds ERISA Preempts Hospital's Breach of Contract Claims Against Health Plans.
  Temple Univ. Hosp., Inc. v. Group Health Plan, Inc.
  
  
• United States District Court Dismisses Claim That MMA Is Unconstitutional.
  Independent Living Center of Southern California v. Leavitt
  
  
• Third Circuit Vacates Class Certification, Says More Detail Needed.
  Wachtel v. Guardian Life Insurance Co. of America
  
  
• Court Upholds Insurer's Determination That Injuries Caused By DUI Are Excluded.
  Carter v. ENSCO, Inc.
  
  
• Florida Appellate Court Reinstates Suit Against Insurer For Using Medicare Rates As "Usual, Customary and Reasonable."
  Adventist Health System / Sunbelt, Inc., etc. v. Blue Cross and Blue Shield, etc., et al.
  
  
• FTC Settles Dispute With Puerto Rico Association of Endodontists, Corp.
  In the Matter of Puerto Rico Assn. of Endodontists, Corp.
  
  

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June 2006 Managed Care Lawsuit Watch [full version]

• Supreme Court Opines On Subrogation.
  Sereboff v. Mid Atlantic Medical Services, Inc.
  
  
• District Court Says that Attorney-Client Privilege May Not Cover Communications If Client Is A Fiduciary.
  McCoy, et al. v. Health Net, Inc., et al.
  
  
• Florida Supreme Court Says That Federal Anti-Kickback Law Preempts Florida State Anti-Kickback Law.
  Florida v. Harden
  
  
• Federal District Court Broadly Interprets Medicare Part D's Preemption Provision.
  Uhm et al. v. Humana, Inc. et al.
  
  
• Kentucky Any Willing Provider Law Not Applicable to Ohio-Based Provider Network.
  Florence Urgent Care v. Healthspan Inc.
  
  
• Court Finds that Claims Appeals Procedures are Unreasonable if Entity Deciding Appeal is Same as that Made Initial Denial.
  St. Joseph's Hospital of Marshfield, Inc. v. Carl Klemm Inc.
  
  
• Pennsylvania Federal Court Retains Jurisdiction On Basis of Benefits Assignment.
  Children's Hospital of Philadelphia v. Tricorp Enterprises Ltd. Flexible Benefits Plan
  
  
• GAO Recommends that CMS Reopen Contract Bid After Improper Communications Reported.
  In the Matter of CIGNA Government Services, LLC
  
  
• Effective Date of Class Action Fairness Act ("CAFA") Receives Liberal Interpretation.
  Prime Care of Northeast Kansas, LLC et al. v. Humana Ins. Co., et al.
  
  
• Pharmacy Benefit Manager Resolves Allegations That It Improperly Retained Drug Rebates
  Chao v. Pharmaceutical Care Network
  
  
• Federal Circuit Court Finds that Government is Not Party In Interest to Breach of Contract Action Against TRICARE Administrator.
  Board of Trustees of Bay Medical Center et al. v. Humana Military Healthcare Services, Inc.
  
  
• Health Fund Abused Discretion In Terminating Coverage.
  Janssen v. Minneapolis Auto Dealers Benefit Fund
  
  
• ERISA Removal Jurisdiction Applies to Claim of Violation of Texas' Any-Willing Provider Law.
  Quality Infusion Care, Inc. v. Aetna Health, Inc.
  
  

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May 2006 Managed Care Lawsuit Watch [full version]

• Court Finds that Retiree Plan Properly Refused to Cover TMJ Surgery Services.
  Angel v. Boeing Co. Retiree Health and Welfare Benefit Plan
  
  
• District Court Allows State Law Counterclaims to Proceed, Finding That an Insurer Has a "Special Relationship" With Its Contracted Providers.
  HealthNow New York Inc. v. APS Healthcare Bethesda, Inc.
  
  
• U.S. District Court Refuses to Hear Case Regarding Retroactive Applicability of State Any-Willing Provider Law.
  Arkansas Blue Cross and Blue Shield v. St. Vincent Infirmary Medical Center
  
  
• Idaho District Court Dismisses Antitrust Claims Brought Against Blue Shield of Idaho and Blue Cross of Idaho.
  Government Employees Medical Plan v. Regence Blue Shield of Idaho, Inc.
  
  
• District Court Dismisses Claim That Beneficiary is a "Plan Fiduciary," But Uses Equitable Remedy to Effectuate Plan's Subrogation Rights.
  Tisl v. Slick
  
  
• Washington Court Upholds Insurance Commissioner's Decision to Prohibit Blue Cross Conversion.
  Premera v. Kreidler
  
  
• Eleventh Circuit Reverses Prior Order Certifying Class Action Against Blue Cross and Blue Shield of Alabama.
  Heffner v. Blue Cross and Blue Shield of Alabama, Inc.
  
  
• District Court Refuses to Certify Class Action Suit Against UniCare Plans in Infusion Therapy Case.
  Moffat v. UniCare Midwest Plan Group 31451
  
  
• Oregon District Court Determines That ERISA Preempts State Law Claims Against Third-Party Administrator.
  Zavala v. Trans-System, Inc.
  
  
• New Jersey District Court Dismisses ERISA Claims Against PBM.
  Mulder v. PCS Health Systems Inc.
  
  
• Arizona District Court Grants Attorneys' Fees to Medicare Advantage Participant Who Did Not Receive Timely Reimbursement.
  Wallis v. Leavitt
  
  
• Michigan District Court Dismisses Antitrust Claims Against Vision Plan.
  Brighton Optical, Inc. v. Vision Service Plan
  
  
• Wisconsin Insurer Counterclaims Against Wisconsin Health System, Alleging Violation of Antitrust Laws.
  Aurora Health Care, Inc. v. Wisconsin Physicians Insurance Service Corp.
  
  

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April 2006 Managed Care Lawsuit Watch [full version]

• Beneficiary's Unanswered Demand to Resolve Subrogation Issue Is Not Evidence of Health Plan's Waiver of Subrogation Claim.
  Mississippi Power Co. Medical Benefits Plan v. Welch
  
  
• Sixth Circuit Says Michigan Law Does Not Preempt RICO Suit.
  Genord v. Blue Cross & Blue Shield of Michigan
  
  
• DC Court Says Bipolar Disorder May Not Be A "Mental Illness."
  Fitts v. Unum Life Ins. Co. of America
  
  
• Physicians' Antitrust Claims Against United Healthcare Not Subject to Arbitration.
  Academy of Medicine of Cincinnati v. Aetna Health, Inc., et al.
  
  
• New Jersey Court Upholds State Agency's Approval of United Healthcare's Acquisition of Oxford Health Plans.
  Medical Society of New Jersey v. Bakke
  
  
• Health Plan Does Not Have to Pay Hospital For Full Amount Billed.
  University Hospitals of Cleveland v. South Lorain Merchants Assn. Health & Welfare Benefit Plan and Trust
  
  

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March 2006 Managed Care Lawsuit Watch [full version]

• Sixth Circuit upholds health plan's denial of benefits for self-inflicted wounds.
  Mathis v. Mahle Inc.
  
  
• Court orders Tennessee insurer to pay provider at contracted rates - not CHAMPUS rates - for high-dollar services.
  Baptist Physician Hospital Organization, Inc. v. Humana Military Healthcare Services, Inc.
  
  
• Seventh Circuit determines that company is not required to provide free lifetime health benefits to retirees.
  Barnett v. Ameren Corp.
  
  
• District Court refuses to grant federal jurisdiction on basis of ERISA counter-claim.
  Aetna Health v. Kirshner
  
  
• California state court says that out-of-network physicians may balance-bill patients.
  Prospect Medical Group Inc. v. Northridge Emergency Medical Group
  
  
• Court finds that health insurer did not violate contractual or fiduciary duties by refusing to waive its right of subrogation.
  Borden v. Blue Cross and Blue Shield of Western New York
  
  
• Georgia back pain clinic owners plead guilty to health care fraud.
  United States v. Topel
  
  

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February 2006 Managed Care Lawsuit Watch [full version]

• Beard v. Benicorp Insurance Co.
  The District Court for the Western District of Tennessee determined that the Employee Retirement Income Security Act ("ERISA") preempts a Tennessee common law requirement that an insurer provide notice of the nonpayment of the insurance premium by the insured's employer. more...
  
  
• CareFirst of Maryland, Inc. v. First Care, P.C.
  The Fourth Circuit affirmed a district court's grant of summary judgment for First Care, P.C., ("First Care") a physician group, which was the defendant in a trademark infringement action brought by CareFirst of Maryland ("CareFirst"). more...
  
  
• In re Managed Care Litigation
  Judge Moreno of the U.S. District Court for the Southern District of Florida gave final approval to a proposed settlement involving WellPoint, Inc. ("WellPoint") that would resolve the claims against WellPoint in the national class actions filed by over 700,000 physicians against the nation's major managed care companies. more...
  
  
• New York Insurance Department Fines CIGNA
  CIGNA Healthcare of New York, Inc. ("CIGNA") was fined $150,000 by the New York Superintendent of Insurance (the "Department") for allegedly neglecting to respond to consumer complaints in a timely fashion. more...
  
  
• Knieriem v. Group Health Plan
  The court of appeals for the Eighth Circuit affirmed the dismissal of a plan participant's request for restitution for the plan's refusal to approve a stem cell transplant for the participant. more...
  
  
• In Re: Managed Care Litigation
  On January 31, 2006, Judge Moreno of the U.S. District Court for the Southern District of Florida granted PacifiCare Health Systems, Inc.'s ("PacifiCare's") motion for summary judgment in In Re: Managed Care Litigation, MDL No. 1334, 00-1334-MD-Moreno. more...
  
  

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January 2006 Managed Care Lawsuit Watch [full version]

• Capital Blue Cross v. Commissioner
  The United States Court of Appeals for the Third Circuit found that the U.S. Tax Court erred in determining that a Blue Cross Blue Shield organization had a zero basis in cancelled subscriber contracts and thus could not claim the cancelled contracts as a loss on its tax return. more...
  
  
• Central States Southeast and Southwest Areas Health and Welfare Fund v. Merck-Medco Managed Care, L.L.C.
  The Second Circuit Court of Appeals recently remanded a case to the U.S. District Court for the Southern District of New York in order for it to determine whether health plan beneficiaries can demonstrate sufficient injury-in-fact resultant from alleged activities of a pharmacy benefit manufacturer. more...
  
  
• In re Hartwig v. Commissioner, Connecticut Department of Social Services
  The Connecticut Freedom of Information Commission (the "Commission") ruled that Anthem Blue Cross and Blue Shield of Connecticut, Community Health Network of Connecticut, Health Net of Connecticut and WellCare of Connecticut, each of which run Medicaid health maintenance organization ("HMOs"), are subject to the state's Freedom of Information Act ("CN-FOIA"). more...
  
  
• Hagan v. Vision Service Plan
  The U.S. District Court for the Eastern District of Michigan granted preliminary injunctive relief to three doctors ("Plaintiffs") whom Vision Service Plan ("VSP") terminated for failing to comply with VSP's franchise affiliation requirements. more...
  
  
• United States v. UnitedHealth Group, Inc. and PacifiCare Health Systems, Inc.
  One day after California's Department of Managed Health Care ("DMHC") and Department of Insurance ("DOI") approved the proposed merger between UnitedHealth Group, Inc. ("United") and PacifiCare Health System, Inc. ("PacifiCare"),the U.S. Department of Justice ("DOJ") entered into a consent agreement to resolve antitrust allegations relating to the proposed acquisition. more...
  
  

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December 2005 Managed Care Lawsuit Watch [full version]

• In re Arbitration between United Healthcare of Illinois Inc. and Advocate Health Care Network
  A panel of arbitrators dismissed United Healthcare of Illinois' ("United") price fixing and group boycott antitrust claims against Advocate Health Care, a Chicago health system that owns eight hospitals and either employs or is affiliated with over 2,500 physicians. more...
  
  
• Kentucky Office of Insurance fines Anthem Health Plans of Kentucky, Inc.
  The Kentucky Office of Insurance ("KOI") ordered Anthem Health Plans of Kentucky, Inc. ("Anthem") to refund approximately $23.7 million to more than 81,000 individuals enrolled in Anthem's Medicare supplement plans. more...
  
  
• Life Care Centers of America v. CalOptima
  The California Court of Appeals, Fourth District, ruled that a county health system providing services to Medi-Cal beneficiaries through contracts with providers did not violate state law by requiring long-term care providers to submit treatment authorization requests within 21 days of a patient's admission. more...
  
  
• Merkle v. Aetna Health, Inc. / Vista Healthplan Inc. / Health Options Inc. / Neighborhood Health Partnership Inc.
  A Florida Circuit Court held that there is no private right of action under a provision of the Florida Health Maintenance Organization ("HMO") statute that governs reimbursement in cases where a provider does not have a contract with a HMO. more...
  
  
• Neighborhood Health Partnership, Inc. v. Fischer
  The District Court of Appeals for Florida's Third Circuit reversed the trial court's grant of class certification in a suit brought by a local doctor against a South Florida HMO alleging that the HMO regularly engaged in downcoding. more...
  
  
• New York Insurance Department fines 22 health insurers
  The New York State Insurance Department levied fines against 22 health insurers and HMOs for alleged violations of New York's prompt pay law. more...
  
  
• In the Matter of North Texas Specialty Physicians
  The Federal Trade Commission ("FTC") unanimously affirmed a ruling by an Administrative Law Judge ("ALJ") that North Texas Specialty Physicians ("NTSP") illegally fixed prices in contracting with health insurers. more...
  
  

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November 2005 Managed Care Lawsuit Watch [full version]

• Academy of Medicine of Cincinnati v. Aetna Health Inc.
  Courts in Ohio and Kentucky have given preliminary approval to a settlement agreement between Cincinnati area physicians and Anthem Blue Cross and Blue Shield. The courts previously approved similar settlements with Humana and Aetna. more...
  
  
• Georgia Insurance Commissioner proposes to fine United HealthCare of Georgia, Inc.
  On November 11, 2005, Georgia's Insurance Commissioner announced the scheduling of a show-cause hearing, during which United Healthcare of Georgia will have the opportunity to contest a $2.4 million fine for alleged prompt pay law violations. more...
  
  
• In re: Managed Care Litigation
  Humana announced that it has reached an agreement to settle the national class action in which over 700,000 physicians had alleged that Humana and other major managed care companies conspired to systematically underpay the physicians. more...
  
  
• Medical Associates Health Plan, Inc. v. CIGNA Corp.
  An Iowa federal district court determined that a health insurance company was not permitted to unilaterally terminate a group insurance contract with a health maintenance organization ("HMO") after the insurer sold a subsidiary whose employees had utilized the HMO's services. more...
  
  
• Pagarigan v. Aetna U.S. Healthcare of California, Inc.
  The California Court of Appeals concluded that California Civil Code § 3428, concerning duties of health care service plans and managed care entities, imposes a duty of care on HMOs that contract out medical care responsibilities and coverage decisions to providers. more...
  
  
• Viola v. California Department of Managed Care
  The California Court of Appeals ruled that the California Department of Managed Health Care (the "Department") did not violate the right of health plan participants to a civil jury trial when the Department approved health plan contracts that included mandatory binding arbitration provisions. more...
  
  

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October 2005 Managed Care Lawsuit Watch [full version]

• Ahmad v. Aetna U.S. Healthcare
  The United States District Court for the Eastern District of Pennsylvania remanded a lawsuit by a physician against Aetna U.S. Healthcare to state court because it found no basis for federal jurisdiction. more...
  
  
• Collins v. Anthem Health Plans, Inc.
  The Connecticut Supreme Court determined that a state trial court erred in granting class certification in a complaint by physicians and physician groups against Anthem Health Plans, Inc. ("Anthem"). more...
  
  
• Harris Methodist Fort Worth v. Sales Support Services Inc. Employee Health Care Plan
  The Fifth Circuit reversed a grant of summary judgment in favor of a self-insured employee welfare benefit plan by the District Court for the Northern District of Texas, finding that an expectant mother had sufficiently assigned her benefits claim on behalf of her twins to the admitting hospital. more...
  
  
• In re Managed Care Litigation
  On September 26, Judge Moreno of the U.S. District Court for the Southern District of Florida gave final approval to proposed settlements involving Health Net Inc. and Prudential Financial Inc. that would resolve the claims against those companies in the national class actions filed by over 700,000 physicians against the nation's major managed care companies. more...
  
  
• McDonald v. Household International Inc.
  The Seventh Circuit reversed a district court's dismissal of a complaint based on state law claims, holding that although the claims were preempted by ERISA, the facts alleged were sufficient to permit the case to go forward in a claim under ERISA. more...
  
  
• Medical Staff of Doctors Medical Center in Modesto v. Kamil
  A California court held that an arbitration clause in a contract between a health insurer and a hospital employing a group of physicians did not compel the physicians to arbitrate defamation claims against the health insurer. more...
  
  
• Minnesota v. Medica Health Plans
  The Minnesota District Court for Hennepin County dismissed a suit brought by the Minnesota Attorney General that alleged wrongdoing by the Board of Medica Health Plans ("Medica"), finding that there was no evidence that Board members acted improperly in carrying out their court-ordered responsibilities. more...
  
  
• Nechis v. Oxford Health Plans, Inc.
  The United States Court of Appeals for the Second Circuit affirmed the dismissal of two health benefit plan participants' claims that Oxford Health Plans ("Oxford") engaged in deceptive practices in violation of ERISA. more...
  
  
• Tow Distributing Inc. v. Blue Cross and Blue Shield of Minnesota
  A Minnesota court approved settlement of a class-action lawsuit brought by employer groups challenging the plans of Blue Cross and Blue Shield of Minnesota ("BCBSMN") to distribute the proceeds of its tobacco suit. more...
  
  
• U.S. v. AdvancePCS
  On September 7, pharmacy benefit manager AdvancePCS reached agreement with the federal government to settle False Claims Act and Public Contract Anti-Kickback Act claims that had been brought against it on the basis of its financial relationships with pharmaceutical manufacturers and customers. more...
  
  

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September 2005 Managed Care Lawsuit Watch [full version]

• Brown v. Wiener
  The U.S. District Court for the Eastern District of Pennsylvania granted defendant Aetna's motion for judgment on the pleadings, finding that plaintiff's negligence claim was preempted under the Employee Retirement Income Security Act ("ERISA"). more...
  
  
• Cooperstein v. Independence Blue Cross
  The U.S. District Court for the Eastern District of Pennsylvania ruled that ERISA preempted claims brought by prescription drug benefit plan insureds against their insurer and a pharmacy benefits manager ("PBM") that were alleged to have improperly refilled prescriptions through mail-order pharmacy services. more...
  
  
• Daley v. Marriott International Inc.
  The Eighth Circuit Court of Appeals held that ERISA preempts Nebraska's mental health parity law as applied to self-funded ERISA plans. more...
  
  
• International Union of Operating Engineers Local No. 68 Welfare Fund. v. Merck & Co.
  A New Jersey trial court granted a motion for certification of a third-party payor class in a suit against Merck for misrepresenting the safety of Vioxx. more...
  
  
• In re Managed Care Litigation
  The District Court for the Southern District of Florida granted Defendants' motion for summary judgment on all "missing months" capitation claims in a long-running case before Judge Moreno. more...
  
  
• Jackson, Tennessee Hosp. Co. v. West Tennessee Healthcare, Inc.
  The Sixth Circuit Court of Appeals affirmed a lower court decision holding that the allegedly anticompetitive actions of a hospital district were authorized by the plain language of a Tennessee statute. more...
  
  
• North Jackson Pharmacy v. Caremark Rx Inc.
  The U.S. District Court for the Northern District of Illinois held that it would apply the rule of reason as opposed to the per se rule in analyzing whether the joint administration of prescription drug benefit plans by PBMs and drug plan sponsors violated Section 1 of the Sherman Act. more...
  
  
• Smelik v. Mann
  A Texas jury awarded $7.4 million in actual damages to the family of an HMO participant who died from complications of acute renal failure. more...
  
  
• U.S. ex rel. Garner v. Anthem Insurance Companies Inc.
  Anthem Insurance Companies ("Anthem") agreed to pay the United States $1.5 million to settle allegations that from 1992 through 2002. more...
  
  
• U.S. ex rel. Morton
  The Tenth Circuit affirmed a district court dismissal of a qui tam action brought against an ERISA plan because the relators had failed to allege a "false or fraudulent" claim under the federal False Claims Act. more...
  
  

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August 2005 Managed Care Lawsuit Watch [full version]

• AdvancePCS v. Bauer
  The Georgia Court of Appeals ruled on July 13, 2005 that the Employee Retirement Income Security Act ("ERISA") did not preempt a class action brought by health plan participants alleging that two pharmacy benefit management companies ("PBMs") and two mail order pharmacies were unjustly enriched by the companies' wrongful classification of a generic drug as a brand name drug. more...
  
  
• AmeriChoice of Pennsylvania, Inc.
  AmeriChoice of Pennsylvania, Inc. has agreed to pay $1.6 million, to enter into a corporate integrity agreement, and to maintain a claims processing system that will allow providers to query the status of unsettled claims, to settle allegations by the U.S. Attorney for the Eastern District of Pennsylvania and the HHS OIG that the company violated the False Claims Act. more...
  
  
• Bell v. Blue Cross of California
  The Court of Appeals of California, Second Appellate District, held that Blue Cross of California must pay a "reasonable amount" to Dr. Mark R. Bell, an emergency room physician who provides services to the plan's enrollees but did not have a contract with the company. more...
  
  
• Fine imposed by California Department of Managed Health Care on Blue Cross of California
  The California Department of Managed Health Care ("DMHC") fined Blue Cross of California $150,000 for allegedly overcharging nearly 45,000 debit and credit card customers a total of nearly $12 million in premiums. more...
  
  
• Lifecare Hospitals, Inc. v. Health Plus of Louisiana, Inc.
  The Fifth Circuit Court of Appeals held that a health plan participant may elect to receive Consolidated Omnibus Budget Reconciliation Act ("COBRA") continuation benefits after the 60 day minimum election period specified in COBRA if plan documents are silent with respect to the maximum length of the election period. more...
  
  
• In re: Managed Care Litigation
  On July 11, 2005, WellPoint Inc. announced that it will pay as much as $198 million to settle the national class action in which 700,000 physicians alleged that WellPoint and other major managed care companies conspired to systematically underpay the physicians. more...
  
  
• Prudential Insurance Co. of America v. National Park Medical Center Inc. ("Prudential II")
  The Eighth Circuit Court of Appeals found the Arkansas any-willing-provider ("AWP") law (Ark. Code Ann. § 23-99-204) preempted as it applies to self-funded ERISA plans. more...
  
  
• State v. Cohen and State v. Morreale
  Two former executives of an insolvent HMO have been indicted for Medi-Cal fraud, grand theft, perjury, and filing false corporate financial reports. more...
  
  
• In re Union Pac. R.R. Employment Practices Litig.
  Union Pacific Railroad lost its motion for summary judgment in a class action lawsuit brought by its female employees for excluding prescription contraception coverage from its health plans. more...
  
  
• Virginia Academy of Clinical Psychologists, et al. v. Group Hospitalization & Medical Services d/b/a Blue Cross/Blue Shield of the National Capital Area, et al.
  The D.C. Court of Appeals affirmed a decision by the Superior Court granting Defendants' motion for summary judgment on a common law claim of fraudulent misrepresentation. more...
  
  

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July 2005 Managed Care Lawsuit Watch [full version]

• Christianson v. Poly-America Inc. Medical Benefit Plan
  The Eighth Circuit affirmed a district court decision granting summary judgment to Plaintiff on the ground that Defendant had abused its discretion in denying a claim for benefits under an employer-sponsored plan. more...
  
  
• Cleghorn v. Blue Shield of California
  The Ninth Circuit affirmed a district court's dismissal of Plaintiff's complaint in a suit involving state-law claims for an alleged violation of an emergency services provision of the California Health and Safety Code. more...
  
  
• Consumers Union v. New York
  The New York Court of Appeals held that Plaintiffs failed to state a viable cause of action when they challenged legislation that permitted the conversion of Empire Blue Cross and Blue Shield ("Empire"), the state insurer of last resort, from a non-profit to a for-profit corporation. more...
  
  
• Friedman Professional Management Co. v. Blue Shield of California
  In an unpublished opinion, the California Court of Appeals ruled that a health insurer's request for declaratory relief for money held in a patient's trust account was in fact a claim for money damages for health benefits already conferred, and was thus not actionable under ERISA. more...
  
  
• In Re Lorazepam & Clorazepate Antitrust Litigation
  On June 1, 2005, a federal jury found that generic drug manufacturer Mylan Laboratories Inc. had violated state antitrust laws, and awarded approximately $12 million in damages to four health insurers. more...
  
  
• Torres v. Dean Health Plan, Inc.
  The Wisconsin Court of Appeals affirmed a decision by the lower court dismissing an action Plaintiff brought against her HMO for exercising subrogation rights under Wisconsin statutory law. more...
  
  
• United States v. Capital Group Health Services of Florida, Inc.
  In a qui tam action that alleged a scheme between a hospital, an HMO and a psychiatrist for submission of false claims under the Medicare and Medicaid programs, a federal district court dismissed the action as against the hospital and the HMO, but denied a motion to dismiss the action as against the psychiatrist. more...
  
  
• Zoblotsky v. Tenet Choices, Inc.
  A federal district court refused to dismiss a state-law negligence claim alleging that a health insurer's decision to only provide coverage for a generic form of a drug required an enrollee to change medications and suffer "significant clinical problems" and physical debilitation. more...
  
  

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June 2005 Managed Care Lawsuit Watch [full version]

• Corporate Integrity Agreement between the Office of Inspector General of the Department of Health and Human Services and the Hawaii Region of Kaiser Foundation Health Plan, Inc., et al.
  Kaiser Foundation Health Plan Inc. reached an agreement with the Office of Inspector General of the Department of Health and Human Services ("HHS") to pay $1 million to settle allegations that Kaiser submitted inaccurate claims to Medicare. more...
  
  
• Dolan v. Excellus, Inc.; Medical Society of the State of New York v. Excellus, Inc.
  Excellus Blue Cross Blue Shield, a Rochester New York health plan, agreed to settle lawsuits filed by the Medical Society of the State of New York and a class of physicians alleging breach of contract and denial, purposeful delay or reduction in payments to physicians. more...
  
  
• Heartland Surgical Specialty Hospital v. Midwest Division Inc.
  A Kansas City-area specialty surgical hospital filed an antitrust lawsuit in the U.S. District Court for the District of Kansas, alleging that traditional acute-care hospitals had colluded with managed care insurers to prevent the specialty surgical hospital from gaining access to managed care network contracts. more...
  
  
• Hill v. Blue Cross and Blue Shield of Michigan
  The Sixth Circuit reversed the dismissal of a complaint against Blue Cross and Blue Shield of Michigan ("BCBSM") for breach of fiduciary duties under the Employee Retirement Income Security Act ("ERISA"), finding that requiring Plaintiffs to exhaust administrative remedies would be futile. more...
  
  
• In the Matter of: Inquiry into the Charitable Obligations of GHMSI/CareFirst in the District of Columbia
  Commissioner Mirel of the District of Columbia Department of Insurance, Securities and Banking ("DISB") issued a report addressing the alleged charitable obligations of Group Hospitalization and Medical Services, Inc. ("GHMSI"), the Blue Cross Blue Shield plan for the Washington, D.C. area. more...
  
  
• Insurance Federation of Pennsylvania Inc. v. Pennsylvania Insurance Dept.
  The Commonwealth Court of Pennsylvania dismissed a lawsuit challenging a notice issued by the Pennsylvania Insurance Department (the "Department") directing plans to cover alcohol and substance abuse treatment upon referral. more...
  
  
• Jones v. LMR International
  ERISA preempts state law negligence, breach of contract, fraud, breach of fiduciary duty and bad faith failure to pay claims brought by beneficiaries of an ERISA plan, even where the plan at issue had lapsed at the time of the suit. more...
  
  
• Maine Coast Memorial Hospital v. Sargent
  The United States District Court for the District of Maine dismissed a third-party complaint against Harvard Pilgrim Health Care ("Harvard Pilgrim"). more...
  
  
• RenCare, Ltd. v. United Medical Resources, Inc.
  A Texas appeals court held that the trial court had subject matter jurisdiction over the state law claims of a kidney dialysis provider because the claims did not "arise under" the Medicare Act. more...
  
  
• Sylvester v. Cigna Corp., et al.
  The United States District Court for the District of Maine denied a motion seeking approval of a proposed class action settlement between insurers and plan participants over alleged collection of improper coinsurance payments. more...
  
  
• Telecare Corp. v. Leavitt
  The United States Court of Appeals for the Federal Circuit affirmed the decision of the United States District Court for the Northern District of California in a suit regarding the liability of an employer for Medicare payments made to the company's employees. more...
  
  
• Westside EKG Assoc. v. Foundation Health
  Service providers may bring a breach of contract action under the "prompt pay" provision of Florida's Health Maintenance Association Act (the "Act") against health maintenance organizations ("HMOs") who fail to pay for claims within the Act's mandated pay period. more...
  
  

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May 2005 Managed Care Lawsuit Watch [full version]

• Boales v. Blue Shield of California
  The Court of Appeals of the State of California, Second Appellate District, affirmed the lower court's decision dismissing a complaint brought by Michael Boales and Alice Marion La Rue-Boales against Blue Shield of California, Health Net of California, Inc., and Health Net, Inc. and several health care providers. more...
  
  
• Chatham Surgicare Ltd. v. Health Care Service Corp.
  The Illinois Appeals Court held that the circuit court erred in dismissing a medical service corporation's promissory estoppel claim against Health Care Services Corporation, but affirmed the lower court's dismissal of a fraud claim. more...
  
  
• Illinois Health Maintenance Guaranty Association v. Shapo
  The Illinois Appeals Court upheld the decisions of a trial court and the Director of the Illinois Department of Insurance (the "Department") awarding $22 million to health care providers for services rendered to participants of the now insolvent MedCare HMO. more...
  
  
• In the Matter of UAHC Health Plan of Tennessee, Inc.
  The Commissioner for the Department of Commerce and Insurance has determined that there are sufficient grounds for imposing administrative supervision on UAHC Health Plan of Tennessee. more...
  
  
• In the Matter of: Inquiry into the Charitable Obligations of GHMSI/CareFirst in the District of Columbia
  Commissioner Mirel of the District of Columbia Department of Insurance, Securities and Banking ("DISB") issued a report addressing the alleged charitable obligations of Group Hospitalization and Medical Services, Inc. ("GHMSI"), the Blue Cross Blue Shield plan for the Washington, D.C. area. more...
  
  
• J.E. Pierce Apothecary Inc. v. Harvard Pilgrim Health Care Inc.
  The U.S. District Court for the District of Massachusetts ruled that an HMO and a pharmacy operator violated the state's Any Willing Provider ("AWP") law and the state's unfair trade practices / consumer protection statute (MGL ch. 93A) by renegotiating an agreement that would keep the pharmacy operator's wholly-owned PBM as the HMO's dominant drug supplier. more...
  
  
• Levine v. United Healthcare Corp.
  The United States Court of Appeals for the Third Circuit held that ERISA § 502(a) preempts plan participants' claims that health plans violated New Jersey law by attempting to enforce subrogation and reimbursement liens. more...
  
  
• Parnell v. Adventist Health System/West
  The California Supreme Court held that a hospital seeking to assert a lien under the state's Hospital Lien Act ("HLA") can only do so if the patient owes an underlying debt to the hospital. more...
  
  
• State Farm Mutual Auto. Ins. Co. v. Mallela
  The New York Court of Appeals held that under New York's no fault insurance laws, an insurance company may refuse to pay a fraudulently incorporated medical services corporation for a claim assigned to the corporation by an insured. more...
  
  

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April 2005 Managed Care Lawsuit Watch [full version]

• Abraham v. Intermountain Health Care Inc.
  A group of optometrists brought an action in the District Court of Utah against Intermountain Health Care ("IHC") alleging illegal tying arrangements, an illegal group boycott, and a conspiracy or attempt to monopolize the hospital and surgical facilities market. more...
  
  
• CareFirst of Maryland, Inc. v. First Care, P.C.
  The District Court for the Eastern District of Virginia granted summary judgment for First Care, P.C., a physician group, which was the Defendant in a trademark infringement action brought by CareFirst of Maryland. more...
  
  
• Geddes v. United Staffing Alliance Employee Medical Plan
  The United States District Court for the District of Utah held that an ERISA plan fiduciary unreasonably interpreted the plan's provision to pay the "usual and customary amount" for services from out-of-network providers to mean that the plan would only pay an out-of-network provider the same discounted amount it had contractually arranged to pay in-network providers. more...
  
  
• Maine Coast Memorial Hospital v. Sargent
  The U.S. District Court for the District of Maine held that ERISA preempted state law claims brought by a health plan participant against her employer, Wal-Mart Stores Inc., for allegedly unpaid medical bills. more...
  
  
• In re Preferred Health Services, Inc.
  The FTC announced a proposed consent order with Preferred Health Services, Inc., an organization consisting of over 100 physicians and a hospital in the Seneca, South Carolina area, to settle charges that Preferred Health had orchestrated agreements among its member physicians to fix the prices charged to health plans and other payors. more...
  
  
• Tourdot v. Rockford Health Plans Inc.
  The U.S. District Court for the Western District of Wisconsin granted summary judgment for Defendant Rockford Health Plans, Inc., in a suit for benefits brought under ERISA. Plaintiff Tourdot brought suit after the plan denied him coverage for medical costs incurred following an accident between Tourdot's motorcycle and an automobile. more...
  
  
• Trustees of the Southern Illinois Carpenters Welfare Fund v. RFMS Inc.
  The Seventh Circuit affirmed the district court's ruling that a beneficiary's ERISA-governed employer-sponsored health plan ("RFMS' health plan") explicitly limited payments to $1,000 and is not liable for the participant's $160,000 medical expenses. more...
  
  
• U.S. ex rel. Jiminez v. Health Net, Inc.
  The Tenth Circuit dismissed Plaintiff's appeal of its qui tam action for lack of prosecution sua sponte. more...
  
  

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March 2005 Managed Care Lawsuit Watch [full version]

• Bruun v. Prudential Health Care Plan, Inc.
  On an appeal from a Rule 12(b)(6) dismissal by the District Court of New Jersey, the Third Circuit considered two issues: (1) whether the HMO Act, 42 U.S.C. § 300e, allows an HMO to subrogate recoveries from third parties, and (2) whether Defendant-Appellee Prudential Health Care Plan ("PruCare") was entitled to reimbursement of the reasonable cash value of benefits in lieu of actual costs paid. more...
  
  
• In re Managed Care Litigation
  The District Court for the Southern District of Florida has ordered that, based on the factors set forth in Fed. R. Civ. P. 42, the trial be bifurcated into a liability phase followed, if necessary, by determination of individualized damages to be tried to the same jury. more...
  
  
• Kotler v. PacifiCare of California
  The Second Appellate District of the Court of Appeals of California reversed a district court's ruling in favor of PacifiCare, saying that the HMO unreasonably delayed the referral of a member to a specialty physician, breaching its obligation to provide medical services on a timely basis. more...
  
  
• Reuben-Schneiderman v. Merit Behavioral Care Corp.
  In an unpublished opinion, the Second Circuit affirmed a lower court's determination that ERISA preempted a state negligence claim brought by a participant in a preferred provider organization ("PPO") against a company providing utilization review services to the PPO. more...
  
  

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February 2005 Managed Care Lawsuit Watch [full version]

• Empire Healthchoice Assurance Inc. v. McVeigh
  The Second Circuit Court of Appeals, in a 2-1 decision, ruled that a Federal Employees Health Benefit Act ("FEHBA") -governed health plan administrator cannot sue a beneficiary's estate in federal court under a subrogation provision. more...
  
  
• In re Evanston Northwestern Healthcare Corporation and ENH Medical Group, Inc.
  The Federal Trade Commission ("FTC" or "Commission") withdrew Count III of its complaint filed against Evanston Northwestern Healthcare Corporation ("ENH"), which alleged price-fixing of physicians services in managed care contracts. more...
  
  
• RenCare, Ltd. V. Humana Health Plan of Texas, Inc.
  The Fifth Circuit found that because RenCare's claims against Humana were not inextricably intertwined with a claim for Medicare benefits and because there were no administrative appeals for RenCare to pursue, the district court erred in its partial denial of RenCare's motion to remand its claims to state court and its dismissal of RenCare's claims. more...
  
  
• Rome Ambulatory Surgical Center, LLC v. Rome Memorial Hospital, Inc.
  The case arose when Rome Ambulatory Surgical Center ("RASC") brought an action against Rome Memorial Hospital ("Hospital") and its corporate parent, Greater Affiliates, Inc., alleging violations of Sections 1 and 2 of the Sherman Act and state law claims, including tortious interference with business relations and intentional interference with contractual relations. more...
  
  
• UnitedHealth Group Inc. v. Klay
  In the latest chapter of the ongoing managed care litigation involving federal and state law claims brought by a class of thousands of doctors against major health maintenance organizations, the United States Supreme Court declined to review the September 1, 2004 decision by the 11th Circuit Court of Appeals to allow the physicians to pursue their federal RICO claims as a class. more...
  
  

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January 2005 Managed Care Lawsuit Watch [full version]

• Academy of Medicine of Cincinnati, et al. v. Aetna Health Inc., et al
  Courts in Ohio and Kentucky have given preliminary approval to a $22 million settlement between Aetna, Inc. and Cincinnati area physicians. more...
  
  
• Administrative Committee of the Wal-Mart Associates Health and Welfare Plan v. Willard
  The Tenth Circuit affirmed a district court decision allowing a Wal-Mart sponsored health plan to receive reimbursement out of a beneficiary's settlement proceeds, received after the beneficiary sued Wal-Mart in tort based on an alleged error made by a company pharmacist. more...
  
  
• State Medical Society v. Oxford Health Plans (CT), Inc. / Connecticut State Medical Society v. Connecticare, Inc.
  The Connecticut Supreme Court affirmed a trial court finding that a medical association representing seven thousand physicians lacked standing to bring an action against a managed care company for alleged unfair trade practices, because the medical association's alleged injuries were too remote. more...
  
  
• Kuthy v. Mansheim
  In an unpublished decision, the Fourth Circuit Court of Appeals held that state law malpractice and wrongful death claims brought against an HMO by the husband of a deceased enrollee were completely preempted by ERISA. more...
  
  
• Timmis v. Kaiser Permanente, et al.
  The California Court of Appeal affirmed a trial court's finding that Kaiser Permanente's (Kaiser) "pill-splitting" policy did not violate California's Unfair Competition Law (UCL) or the Consumers Legal Remedies Act (CLRA). more...
  
  

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December 2004 Managed Care Lawsuit Watch [full version]

• American Chiropractic Association, Inc. v. Trigon Healthcare, Inc.
  The U.S. Supreme Court denied certiorari on November 8, 2004, without comment. more...
  
  
• Blue Cross & Blue Shield v. Philip Morris USA Inc.
  The Second Circuit held that third party payers lack standing to bring an action under New York General Business Law § 349 because their claims are too remote. more...
  
  
• Hawaii Mgmt. Alliance Ass'n v. Insurance Comm'r, Hawaii
  The Hawaii Supreme Court ruled that Hawai`i Revised Statutes (HRS) § 432E-6, the state law that allows Hawaii's insurance commissioner to review health plan coverage decisions, is preempted by the Employee Retirement Income Security Act ("ERISA"). more...
  
  
• North Texas Specialty Physicians
  In an initial decision issued on November 15, an Administrative Law Judge ("ALJ") concluded that the FTC proved its allegations that a Texas independent practice association ("IPA") engaged in illegal price fixing and anticompetitive conduct when negotiating contracts between health insurance payors and the IPA's participating physicians. more...
  
  
• Pascack Valley Hospital Inc. v. Local 464A UFCW Welfare Reimbursement Plan
  The Third Circuit decided that a hospital's state law breach of contract claims against a health plan are not preempted by the civil enforcement provision of the Employee Retirement Income Security Act ("ERISA"). more...
  
  
• Ortlieb v. United HealthCare Choice Plans
  United Healthcare's decision to deny coverage for Total Parenteral Nutrition ("TPN") was not an abuse of discretion, according to the Eighth Circuit. more...
  
  
• UnitedHealth Group Inc. v. Klay
  In the latest chapter of the ongoing managed care litigation involving federal and state law claims brought by thousands of doctors against major health insurers, defendants filed a petition for certiorari to the United States Supreme Court to review the September 1, 2004 decision by the 11th Circuit Court of Appeals to allow the physicians to pursue their federal RICO claims as a class. more...
  
  
• Klay v. PacifiCare Health Systems, Inc.
  The Eleventh Circuit upheld a district court decision refusing to compel arbitration of various claims against HMOs. more...
  
  
• UnitedHealthcare of North Carolina, Inc. and United HealthCare Insurance Co.
  The North Carolina Insurance Commissioner announced a voluntary settlement agreement between the North Carolina Department of Insurance and UnitedHealthcare of North Carolina, Inc. and United Healthcare Insurance Co. more...
  
  
• White Consolidated Industries Inc. v. Lin
  The New Jersey Superior Court Appellate Division affirmed a lower court's decision that an employer's self-funded medical benefits plan was a non-insured plan, and was protected by ERISA's deemer clause from state insurance laws such as New Jersey's collateral source rule. more...
  
  

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November 2004 Managed Care Lawsuit Watch [full version]

• California Pacific Medical Center v. Concentra Preferred Systems Inc.
  A federal district court granted defendants Redwood Empire Electrical Workers Health and Welfare Trust Fund and Zenith Administrators, Inc.'s motion to dismiss because the Employee Retirement Income Security Act ("ERISA") preempted state claims. more...
  
  
• Cuccia v. Roberson Advertising Services, Inc.
  The U.S. District Court for the Eastern District of Louisiana held that where an employee sues for medical benefits under ERISA, a health care plan is the only proper defendant. more...
  
  
• Manny v. Central States, Southeast and Southwest Areas Pension and Health and Welfare Funds
  The U.S. Court of Appeals for the Seventh Circuit affirmed a ruling by the U.S. District Court for the Northern District of Illinois, holding that trustees of a health fund did not act unreasonably in refusing coverage for gastric bypass surgery. more...
  
  
• McCoy v. Unicare Life and Health Insurance Co.
  The District Court for the Northern District of Illinois held that where a medical malpractice claim concerns benefit eligibility, rather than a provider's treatment decisions, such a claim is preempted by the Federal Employee Health Benefits Act ("FEHBA"). more...
  
  
• McKenzie-Willamette Hospital v. PeaceHealth
  The United States District Court for the District of Oregon denied motions by PeaceHealth for a new trial and for judgment as a matter of law, upholding a jury's decision that PeaceHealth engaged in anti-competitive behavior that harmed the McKenzie-Willamette Hospital ("McKenzie"). more...
  
  
• Medical Savings Ins. Co. v. HCA, Inc., et al.
  A federal judge granted defendants' motion to dismiss antitrust and state Deceptive and Unfair Trade Practices claims filed by a health insurer against several hospitals in Florida. more...
  
  

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October 2004 Managed Care Lawsuit Watch [full version]

• Cicio v. Does
  Reviewing its February 2003 Cicio v. Vytra decision in light of the U.S. Supreme Court's recent decision in Aetna Health Inc. v. Davila, the Second Circuit Court of Appeals vacated its earlier decision and affirmed the district court's dismissal of a state law medical malpractice claim as preempted by ERISA. more...
  
  
• Connecticut v. Health Net, Inc. (In re Managed Care Litigation)
  In what the Eleventh Circuit described as an issue of first impression, it held that Connecticut had no standing to pursue the ERISA claims of its citizens in its capacity as assignee, because Connecticut failed to show that it had or would suffer actual or imminent harm to a legally protected interest. more...
  
  
• Land v. CIGNA Healthcare of Florida
  The Eleventh Circuit reviewed its July 2003 Land v. CignaHealthcare of Florida decision, which the U.S. Supreme Court had vacated and remanded for consideration in light of Aetna Health Inc. v. Davila, and determined that the Land plaintiff's state law malpractice claims were preempted by ERISA. more...
  
  
• Smith v. United Health Care Services, Inc.
  A federal judge accepted a settlement between UnitedHealth Group and two named plaintiffs in a class action that alleged the company over-billed beneficiaries for their prescription drugs. more...
  
  

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September 2004 Managed Care Lawsuit Watch [full version]

• Aetna and American Dental Association Settlement (In re Managed Care Litigation)
  A federal judge in the U.S. District Court for the Southern District of Florida gave final approval to an agreement between Aetna and the American Dental Association ("ADA"), settling a class action lawsuit brought by 147,000 dentists against Aetna in 2001 for alleged underpayment of patients' out-of-network dental services. more...
  
  
• Community General Hospital Inc. v. Zebrowski
  The United States District Court for the Northern District of New York held that the Employee Retirement Income Security Act ("ERISA") preempted claims against a third party administrator ("TPA") for breach of contract, bad faith processing of a claim, and infliction of emotional distress. Zebrowski, a beneficiary of a plan provided by Lockheed Martin for its employees, commenced an action pro se against the plan's TPA after himself being sued by Community General Hospital in a collection action. more...
  
  
• Klay v. Humana, Inc. (In re Managed Care Litigation)
  In the latest chapter of the ongoing managed care litigation involving federal and state law claims brought by thousands of doctors against major health maintenance organizations, the U.S. Court of Appeals for the 11th Circuit affirmed the District Court of the Southern District of Florida's grant of class certification for the plaintiff's federal RICO claims. more...
  
  
• State Farm Mutual Automobile Insurance Co. v. Blue Cross Blue Shield of Louisiana
  A Louisiana District Judge held that a hospital violated Louisiana's Health Care Consumer Billing and Disclosure Protection Act by filing a lien against an insured patient, seeking to recover payment from the patient in excess of the hospital's contracted reimbursement rate with the patient's health insurer. more...
  
  
• Wachtel v. Guardian Life Ins. Co.
  A lawsuit brought by participants of a Health Net of New Jersey, Inc. point-of-service (POS) plan alleging a breach of fiduciary duty was certified as a class action by the federal judge hearing the case. Original defendant Guardian Life Ins. Co. was dropped from the case. more...
  
  

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August 2004 Managed Care Lawsuit Watch [full version]

• Carter v. Health Net of California Inc.
  The U.S. Court of Appeals for the Ninth Circuit held that a district court did not have subject matter jurisdiction over a health plan enrollee's petition to confirm an arbitrator's award of plan benefits or the health plan administrator's petition to challenge the award, as neither petition presented a federal question. more...
  
  
• Peninsula Regional Medical Center v. Mid Atlantic Medical Services LLC
  The U.S. District Court for the District of Maryland held that a hospital's lawsuit, which alleged that health insurers had violated contractual agreements by failing to promptly pay for services rendered to the insurers' subscribers, was not preempted by ERISA and was improperly removed by the insurers to federal court. more...
  
  
• Johns Hopkins Hospital v. Carefirst of Maryland, Inc.
  In a case that presented an identical question as Peninsula Regional Medical Center and that was decided on the same day, the U.S. District Court for the District of Maryland held that a contracting hospital's state law contract claims against a health insurer were not removable to federal court. more...
  
  

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July 2004 Managed Care Lawsuit Watch [full version]

• Aetna Health Inc. v. Davila and Cigna Healthcare of Texas, Inc. v. Calad
  The United States Supreme Court unanimously ruled in two consolidated cases that ERISA preempted claims brought by individuals against their HMOs under a Texas law that allows patients to sue HMOs for refusing to cover services recommended by their treating physicians. more...
  
  
• Ayotte v. Matthew Thornton Health Plan, Inc.
  A lawsuit by a beneficiary to recover benefits and for breach of fiduciary duty was dismissed for being time barred by a 1-year limitation in the insurance policy, the U.S. District Court for the District of New Hampshire ruled. more...
  
  
• CIGNA HealthCare of Florida v. Land
  The U.S. Supreme Court vacated this decision by the 11th Circuit Court of Appeals, which held that ERISA did not preempt a medical malpractice claim asserted by a patient against an HMO. more...
  
  
• Healthplan Services Inc. v. Gunnells
  The United States Supreme Court denied certiorari, leaving in place the Fourth Circuit Court of Appeals' October 20, 2003 ruling that a U.S. District Court did not abuse its discretion by certifying a class action in a suit brought by employers and employees against a health plan's third party administrator (TPA) for allegedly negligently administering the plan. more...
  
  
• Klassy v. Physicians Plus Insurance Co.
  The U.S. Court of Appeals for the Seventh Circuit upheld a district court's ruling that a medical director's denial of payment for a procedure performed by an out-of-network physician was a pure eligibility decision subject to the exclusive remedies under the Employee Retirement Income Security Act ("ERISA"). more...
  
  
• M-Plan Inc. v. Indiana Comprehensive Health Insurance Assoc.
  The Indiana Supreme Court ruled that HMOs must exhaust administrative remedies before filing a lawsuit against the administrator of the state's high-risk insurance pool. more...
  
  
• Physicians Multispecialty Group v. Health Care Plan of Horton Homes, Inc.
  The Eleventh Circuit Court of Appeals reversed a District Court summary judgment ruling and damages award, and held that an anti-assignment clause in an ERISA plan benefits contract barred the beneficiary's assignee from suing the Plan under ERISA. more...
  
  
• Spry v. Thompson
  The United States District Court for the District of Oregon ruled that Oregon could not charge co-payments to expansion populations covered by a revised version of the Oregon Health Plan (OHP). more...
  
  
• UnitedHealthcare of North Carolina, Inc. and United HealthCare Insurance Co.
  The North Carolina Insurance Commissioner announced a voluntary settlement agreement between the North Carolina Department of Insurance and UnitedHealthcare of North Carolina, Inc. and United Healthcare Insurance Co. more...
  
  
• The Stop & Shop Supermarket Co. and Walgreen Eastern Co. v. Blue Cross & Blue Shield of Rhode Island et al.
  The U.S. Court of Appeals for the First Circuit upheld a district court's ruling that no per se violation of the antitrust laws was shown in an antitrust suit against a health plan and its pharmacy benefit manager for the establishment of a closed network of pharmacies. more...
  
  

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June 2004 Managed Care Lawsuit Watch [full version]

• American Chiropractic Assoc., Inc. v. Trigon Healthcare, Inc.
  Affirming the 2003 decision made by the U.S. District Court for the Western District of Virginia, the Fourth Circuit held that Trigon Healthcare, its affiliated companies, medical doctors and medical associations had not participated in an "anticompetitive conspiracy" and were not in violation of state and federal antitrust laws and the Racketeer Influenced and Corrupt Organizations Act ("RICO"). more...
  
  
• Chambers v. Coventry Health Care of Louisiana, Inc.
  The U.S. District Court for the Eastern District of Louisiana issued an injunction, ordering Coventry, an HMO, to cover a PET fusion scan for Chambers, a 62-year old colon cancer patient, after his physician requested authorization for such procedure. more...
  
  
• QualChoice Inc. v. Rowland
  The U.S. Court of Appeals for the Sixth Circuit dismissed for lack of subject matter jurisdiction an action by a health plan administrator against a beneficiary for reimbursement of medical payments. more...
  
  
• Rizzo v. Bankers Life & Casualty Company
  State law unjust enrichment claims brought by a beneficiary of a collectively bargained health plan against his insurer based on payments the insurer received from the third-party tortfeasor are preempted by ERISA. more...
  
  
• Vista Health Plan Inc. v. Texas Health and Human Services Commission
  Vista Health Plan brought suit against the Texas Department of Health in an attempt to hold the agency responsible for the allegedly inadequate reimbursement rates that Vista received pursuant to its contract with HMO Blue. more...
  
  

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May 2004 Managed Care Lawsuit Watch [full version]

• Artandi v. Buzack
  In a suit by a physician against a plan sponsor, four plan participants, and a third party administrator ("TPA") seeking approximately $100,000 in unpaid medical claims, the U.S. District Court for the Southern District of New York dismissed the claim against the TPA. more...
  
  
• Klay v. Humana Inc. (In re Managed Care Litigation)
  The only appeals challenging CIGNA HealthCare's $550 million settlement of a national class action brought by 700,000 physicians have been dismissed, clearing the way for the terms of the settlement agreement to be implemented. more...
  
  
• Watters v. The Wellness Plan; Cox v. Michigan Health Maintenance Organization Plans, Inc.
  The State of Michigan Insurance Commissioner, Linda Watters, filed two petitions seeking state approval of asset sales of two HMOs—The Wellness Plan and Omnicare. more...
  
  
• York v. Ramsay Youth Services of Dothan
  The U.S. District Court for the Middle District of Alabama ruled that a state court lawsuit alleging fraud, negligence and intentional or reckless infliction of emotional distress brought by plaintiffs who had health insurance through their employment by the defendant was preempted by ERISA. more...
  
  

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April 2004 Managed Care Lawsuit Watch [full version]

• Aetna Life Insurance Co. v. DFW Sleep Diagnostics Center
  In a lawsuit filed by Aetna and a countersuit filed by DFW Sleep Diagnostics Center ("DFW") over a billing dispute, the court ruled that Aetna was obligated to turn over documents detailing performance guarantees it made to sponsors of ERISA benefit plans. more...
  
  
• Carey v. Connecticut General Life Insurance Co.
  A judge in the District of Minnesota ruled that a denial of coverage for treatment for a plan participant's autistic son occurred when a health plan administrator called the participant, not when the HMO sent written notice of the same several months later. more...
  
  
• Crawley v. Oxford Health Plans
  Plaintiff alleged that his health plan wrongfully terminated coverage for failure to pay a premium, and filed suit in state court. more...
  
  
• Heaser v. Blue Cross and Blue Shield of Minnesota
  The U.S. District Court for the District of Minnesota held that the ERISA preempts state claims relating to a plan administrator's denial of benefits. more...
  
  
• Patient Advocates LLC v. Prysunka
  The U.S. District Court for the District of Maine concluded that health claims data that are not held in trust and have not been proven to have economic value are not "plan assets." more...
  
  
• Providence Health Plan v. McDowell
  The Ninth Circuit heard appeals of two actions in which Providence sought to recover benefits it paid to its insureds; action I for breach of contract, filed in state court, and action II for equitable relief under ERISA, filed in federal court. more...
  
  

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March 2004 Managed Care Lawsuit Watch [full version]

• Kroning v. Resurrection Health Care
  The Northern District of Illinois granted summary judgment in favor of Resurrection Health Care, a plan sponsor, on the grounds that the plaintiff had not exhausted administrative remedies prior to filing suit in which she alleged that Resurrection's claims administrator for mental health claims, Accord Behavioral Health, denied pre-certification for her son's treatment. more...
  
  
• N.C. Medical Society v. BlueCross and BlueShield of North Carolina
  The North Carolina Medical Society ("NCMS") filed a lawsuit against BlueCross and BlueShield of North Carolina in state court in Raleigh, alleging that the defendant HMO intentionally engages in unfair and deceptive trade practices, and seeking injunctive relief to force the HMO to change its business practices. more...
  
  

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February 2004 Managed Care Lawsuit Watch [full version]

• Adler v. Unicare Life & Health Insurance Co.
  The U.S. District Court for the Southern District of New York concluded that state contract law claims against a health insurance company were preempted because the plans at issue were employee benefit plans governed by the Employee Retirement Income and Security Act (ERISA). more...
  
  
• Arana v. Ochsner Health Plan
  The United States Supreme Court denied certiorari, leaving in place the Fifth Circuit's July 2003 ruling that ERISA preempts a plan beneficiary's claims that attempts by the plan administrator to recover amounts received by the beneficiary as settlement for personal injuries were impermissible under Louisiana law. more...
  
  
• Baylor Univ. Medical Center v. Arkansas Blue Cross Blue Shield
  The District Court for the Northern District of Texas held that ERISA does not preempt a medical center's claim that an HMO violated state prompt pay laws when it failed to pay the medical center for a subscriber's medical bills. more...
  
  
• Saint Agnes Medical Center v. Pacificare of California, et al
  The California Supreme Court ruled that PacifiCare could invoke the arbitration clause of a health services agreement, even though it had argued in a connected lawsuit that the health service agreement in question was invalid and should not be enforced. more...
  
  

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January 2004 Managed Care Lawsuit Watch [full version]

• Academy of Medicine v. Aetna
  On December 29, 2003, judges from Ohio and Kentucky presided jointly over a hearing on a settlement between Humana Inc. and Cincinnati area physicians. more...
  
  
• In re CIGNA Healthcare of Maine, Inc., and CIGNA Behavioral Health, Inc.
  CIGNA Healthcare of Maine, Inc., and its subsidiary, CIGNA Behavioral Health, Inc., will pay over $2 million in fines and restitution under a Consent Agreement with the Maine Bureau of Insurance and Department of the Attorney General. more...
  
  
• In re Managed Care Litigation
  Judge Moreno denied most parts of a motion brought by managed care companies seeking the dismissal of RICO and other claims against them by more than 700,000 doctors. more...
  
  
• In the Matter of LymeCare, Inc., and Neuner v. Horizon Blue Cross Blue Shield
  The Bankruptcy Court for the District of New Jersey ruled that a provider specializing in the treatment of Lyme's Disease that was assigned benefits by Horizon Blue Cross and Blue Shield ("Horizon") subscribers had standing under ERISA to bring a claim for reimbursement against the health plan for services that it provided to subscribers while it was a participating provider. more...
  
  
• Singh v. Prudential Health Care Plan, Inc.
  The Supreme Court left standing the Fourth Circuit's July 2003 ruling that a state law action seeking restitution for money that a plaintiff paid to comply with defendant HMO's subrogation clause was completely preempted by ERISA because it involved a claim that sought return of benefits under the plaintiff's plan. more...
  
  

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November 2003 Managed Care Lawsuit Watch [full version]

• Academy of Medicine v. Aetna
  Humana Inc. has announced that its subsidiaries, Health Plan of Ohio and Humana Insurance Co., have agreed to settle a suit which alleged that the companies conspired to reduce reimbursement rates to health care providers. more...
  
  
• Aetna Health, Inc. v. Davila; CIGNA HealthCare of Texas, Inc. v. Calad
  The Supreme Court granted certiorari to two lawsuits that raise new questions about ERISA preemption of state lawsuits against HMOs for negligence. more...
  
  
• Difelice v. Aetna U.S. Healthcare
  The Third Circuit affirmed in part and reversed in part a District Court ruling regarding ERISA preemption. more...
  
  
• Duchesne-Baker v. Extendicare Health Servs. Inc.
  The U.S. District Court for the Eastern District of Louisiana held that ERISA does not preempt state tort claims regarding negligent operation of an insurance business. more...
  
  
• Horizon Healthcare of New Jersey, Inc.
  The New Jersey Department of Banking and Insurance announced it had reached an agreement with Horizon Healthcare of New Jersey, Inc. for the resolution of claims handling violations cited by the Department in a market conduct examination. more...
  
  
• In re Managed Care Litigation
  In the ongoing Multi-District Litigation against various insurers, the District Court has granted final approval to a $470 million settlement between Aetna, Inc. and 700,000 physicians that will end a class action lawsuit against Aetna. more...
  
  
• Kaiser Permanente Colorado Region v. Colorado Department of Health Care Policy and Financing
  The Colorado Department of Health Care Policy and Financing has agreed to pay Kaiser Permanent Colorado Region $10 million, plus interest, to settle claims regarding underpayment for care to Medicaid managed care enrollees. more...
  
  
• Palmer v. St. Joseph Healthcare P.S.O., Inc.
  The New Mexico Court of Appeals held that federal law did not preempt a class action claiming misrepresentation by a Medicare+Choice ("M+C") plan. more...
  
  
• People ex rel. Allstate Insurance Company v. Muhyeldin
  The California Court of Appeal, Second Appellate District, rejected an appeal on standing and upheld a jury's award of $8 million to Allstate Insurance Company ("Allstate") after finding that three physicians had fraudulently submitted bills to the insurer. more...
  
  
• Seaway Food Town, Inc. v. Medical Mutual of Ohio
  The Sixth Circuit upheld a district court's grant of summary judgment in favor of Medical Mutual of Ohio ("MMO") in a lawsuit that alleged MMO had breached its ERISA fiduciary duties. more...
  
  

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October 2003 Managed Care Lawsuit Watch [full version]

• Blue Cross Blue Shield of New Jersey, Inc. v. Philip Morris USA, Inc.
  The United States Court of Appeals for the Second Circuit reversed in part and reserved decision in part on a district court's denial of judgment as a matter of law, following a jury award of 17.8 million dollars to Empire Healthcare, Inc., d/b/a Empire Blue Cross & Blue Shield ("Empire") against Philip Morris. more...
  
  
• Collins v. Anthem Health Plans, Inc.
  The Connecticut Supreme Court ruled that a trial court had erred under state law when it certified a class of individual physicians and group practices in a lawsuit against Anthem Health Plans, Inc. more...
  
  
• Connolly v. Aetna U.S. Healthcare, Inc., et al.
  In an unpublished decision, the U.S. District Court for the District of New Jersey held that state law negligence claims arising out of medical treatment to an HMO subscriber were not completely preempted by ERISA, and remanded the case to New Jersey state court. more...
  
  
• Grider v. Keystone Health Plan, Central, Inc., et al.
  The Eastern District of Pennsylvania held that Plaintiffs, providers of services to insureds of Keystone Health Plan Central, Inc., ("Keystone"), could proceed with their suit against Keystone.more...
  
  
• Group Health Plan, Inc. v. Philip Morris USA, Inc.
  The Eighth Circuit affirmed the District of Minnesota's granting of summary judgment on behalf of the defendant- tobacco companies as to the plaintiff-HMOs' damages claims. more...
  
  
• In re Managed Care Litigation
  There have been recent developments in the ongoing Multi-District Litigation being heard before Judge Moreno in the Southern District of Florida concerning alleged RICO and ERISA violations against HMOs. more...
  
  
• Rubin-Schneiderman v. Merit Behavioral Care Corp.
  A federal district court judge ruled that ERISA preempted a participant's state lawsuit against his PPO for his inpatient care for a psychiatric illness.more...
  
  

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September 2003 Managed Care Lawsuit Watch [full version]

• Aetna and American Dental Association Settlement
  Aetna and the American Dental Association announced that they had settled a class action lawsuit brought by 147,000 dentists against Aetna in 2001 for alleged underpayment of patients' out-of-network dental services. more...
  
  
• Blue Cross and Blue Shield of Kansas v. Praeger
  The Kansas Supreme Court upheld the Kansas Insurance Commissioner's decision to block the merger of Blue Cross and Blue Shield of Kansas with Indianapolis-based Anthem, Inc. more...
  
  
• Lefler v. United Healthcare of Utah, Inc.
  The 10th Circuit Court of Appeals upheld a district court's ruling in favor of United HealthCare of Utah in a class action lawsuit brought by some of its insureds. more...
  
  
• U.S. v. Baldwin, et al.
  The U.S. District Court for the District of Columbia denied a motion to dismiss a health care fraud claim, declining to agree with defendants' argument that 18 U.S.C. § 1347 did not apply to fraud against a nonprofit HMO. more...
  
  
• Wheeler, et al. v. Aetna Life Insurance Co.
  The District Court for the Northern District of Illinois denied defendant-Aetna's motion for summary judgment, finding the company's decision to deny benefits for physical, occupational, speech, and other therapies arbitrary and capricious. more...
  
  
  

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August 2003 Managed Care Lawsuit Watch [full version]

• Abbott v. Blue Cross and Blue Shield of Texas, et al.
  The Texas Court of Appeals ruled against the state's Attorney General finding that Blue Cross Blue Shield of Texas was not a charitable organization prior to its merger with Health Care Service Corporation in 1998. more...
  
  
• Arana v. Ochsner Health Plan
  The Fifth Circuit, in a rehearing en banc, held that only complete preemption of a claim under ERISA § 502(a) is required for removal, and that conflict preemption under ERISA §514 is not also required. more...
  
  
• Land v. Cigna
  The Eleventh Circuit held that Land's state law malpractice claim against its HMO was not preempted by ERISA. Land suffered injuries from an animal bite and was treated by an ER doctor and his primary care physician before seeking additional care from a Cigna-approval nurse. more...
  
  
• Singh v. Prudential Health Care Plan, Inc.
  The Fourth Circuit held that the plaintiff's state law action seeking restitution for money she paid to comply with defendant HMO's subrogation clause was completely preempted by ERISA because it involved a claim that sought return of benefits under the plaintiff's plan. more...
  
  
• Vytra Healthcare v. Cicio
  Vytra Healthcare filed a petition for review with the Supreme Court seeking the Court to reject a February decision of the U.S. Court of Appeals for the Second Circuit that allowed Cicio to bring medical malpractice claims on behalf of herself and her deceased husband. more...
  
  
  

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July 2003 Managed Care Lawsuit Watch [full version]

• Care Choices HMO v. Engstrom
  The Sixth Circuit Court of Appeals ruled that there is no federal cause of action for Medicare HMOs seeking reimbursement for benefits paid to an insured who also receives benefits from another source of insurance. more...
  
  
• Horvath v. Keystone Health Plan East, Inc.
  The Third Circuit upheld a district court's decision that Keystone Health Plan East, Inc., a Pennsylvania HMO, had no fiduciary obligation under ERISA to disclose its physician compensation scheme to a subscriber. more...
  
  
• International Healthcare Management v. Hawaii Coalition for Health
  The Ninth Circuit upheld a district court decision that activity by physician and consumer advocacy groups to influence the terms of an HMO's participating provider agreement ("PPA") did not violate federal antitrust laws. more...
  
  
• Nordella v. Blue Cross of California
  Plaintiff Nordella, a California physician, filed a suit against Blue Cross of California, alleging that Blue Cross terminated him as a participating provider in retaliation for his refusal to accept the company's medical coverage policies. more...
  
  
• United States ex rel. Willard v. Humana Health Plan of Texas, Inc.
  The Fifth Circuit upheld a district court's dismissal of a qui tam action against Humana Health Plan of Texas. The action had alleged that Humana had violated the federal False Claims Act by discouraging less healthy patients from joining Humana's Medicare+Choice plan. more...
  
  
  

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This material was prepared by Crowell & Moring attorneys. It is made available on the Crowell & Moring website for information purposes only, and should not be relied upon to resolve specific legal questions.