Health Benefits

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Behavioral health ruling supports benefit claim appeals

Litigating health benefit claim denials is extremely challenging for plaintiffs. Especially under the Employee Retirement Income Security Act — where many cases are decided under the arbitrary and capricious standard of review that upholds an insurance claim denial so long as the basis for the claim decision is viewed as reasonable by a court —overturning […]

Why do health insurers deny claims?

When you are ill and a doctor recommends a course of treatment, you naturally assume that your health insurer will reimburse the cost.  That is not always the case, though, and it is not uncommon for benefits to be denied, especially if the costs are high.  Examples of types of claims that are frequently denied […]

Mental health coverage required under 2008 parity act

Increasing awareness of federal requirements for equal health insurance coverage of mental and physical conditions has led to a spate of litigation relating to health insurance denials. In Christine S. v. Blue Cross Blue Shield of New Mexico, 2019 WL 6974772 (D. Utah, Dec. 19, 2019), the issue was whether the plaintiff pleaded a valid […]

Courts continue to permit plaintiffs to plead simultaneous claims for benefits and breach of fiduciary duty under ERISA

Ever since the Supreme Court’s ruling in Varity Corp. v. Howe, 516 U.S. 489 (1996), courts have grappled with whether plaintiffs who file suit under the Employee Retirement Security Act of 1974 (“ERISA”) can plead simultaneous claims for benefits under § 502(a)(1)(B) along with claims for equitable relief under § 502(a)(3), and if so, under […]

Court questions insurer behavioral health treatment guidelines

Every major insurance company utilizes specific criteria to establish the appropriate medically necessary level of care during behavioral health treatment. But are such guidelines consistent with generally accepted standards for safe and effective treatment for psychiatric conditions? A recent federal court ruling from Connecticut, S.B. v. Oxford Health Insurance Inc., 2019 WL 5726901 (D. Conn., […]