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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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]
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August 2016 Managed Care Lawsuit Watch [full version]
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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]
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June 2015 Managed Care Lawsuit Watch [full version]
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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]
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July 2014 Managed Care Lawsuit Watch [full version]
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April 2014 Managed Care Lawsuit Watch [full version]
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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]
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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]
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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]
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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]
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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]
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December 2010 Managed Care Lawsuit Watch [full version]
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September 2010 Managed Care Lawsuit Watch [full version]
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August 2010 Managed Care Lawsuit Watch [full version]
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May 2010 Managed Care Lawsuit Watch [full version]
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March 2010 Managed Care Lawsuit Watch [full version]
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February 2010 Managed Care Lawsuit Watch [full version]
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December 2009 Managed Care Lawsuit Watch [full version]
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November 2009 Managed Care Lawsuit Watch [full version]
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October 2009 Managed Care Lawsuit Watch [full version]
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September 2009 Managed Care Lawsuit Watch [full version]
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August 2009 Managed Care Lawsuit Watch [full version]
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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]
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January 2009 Managed Care Lawsuit Watch [full version]
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December 2008 Managed Care Lawsuit Watch [full version]
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November 2008 Managed Care Lawsuit Watch [full version]
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September 2008 Managed Care Lawsuit Watch [full version]
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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]
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May 2008 Managed Care Lawsuit Watch [full version]
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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]
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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]
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March 2007 Managed Care Lawsuit Watch [full version]
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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]
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December 2006 Managed Care Lawsuit Watch [full version]
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November 2006 Managed Care Lawsuit Watch [full version]
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September/October 2006 Managed Care Lawsuit Watch [full version]
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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]
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April 2006 Managed Care Lawsuit Watch [full version]
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March 2006 Managed Care Lawsuit Watch [full version]
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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]
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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]
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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.