Health claim denial-standard of review-arbitrary and capricious-medically necessary

Article Abstract:

A decision made in good faith to turn down insurance coverage for treating conditions or complications indirectly or directly pertaining to or precipitated by gastric stapling or weight-loss diversion procedures was affirmed. The affirmation occurred even though the services were needed medically to ameliorate life threatening complications.

HEALTH SERVICES, Insurance Regulation, Health Plan Administration, Laws, regulations and rules, Health care industry, Health insurance industry, Insurance law, Carr, Janet, Gates Health Care Plan

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Focus on plan administration: Administration- health benefits- reimbursement

Article Abstract:

In Reynolds Metals vs Ellis, the suit involved the company's rights to recover costs of health care claims if the injured person received a payment from a liable third party. Ellis sustained serious injuries in a car accident, and received benefits amounting to a large sum. He later sued the third party responsible for the accident and received an even larger settlement. He refused to reimburse the Reynolds Metals plan, despite its plan language reserving the right for it to do so; the courts rejected its claim on the grounds that it did not demonstrate that it was seeking equitable, rather than legal, relief.

Primary aluminum, Aluminum, Primary Aluminum Production, Aluminum industry, Aluminum products, Reynolds Metals Co., RLM, Ellis, Robert

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Cobra - notice; breach of fiduciary duty

Article Abstract:

Rogers Galvanizing breached its fiduciary duty after it did not meet some Consolidated Omnibus Budget Reconciliation Act (COBRA) requirements in the Smith v Rogers Galvanizing case, 1997, of the Tenth Circuit. The case stemmed from Clarence Smith's complaint against his employer, Rogers, which stopped paying the premium on his health insurance. Rogers also told them that their COBRA rights had expired after Smith and his wife failed to elect continuation of coverage within 60 days after Clarence was terminated from work for health reasons. The Tenth Circuit ruled that the oral notice served to the Smiths did not satisfy COBRA requirements as it failed to advise them that they had 45 days left after election to pay the monthly premium.

Employee Benefits & Services, Metal Coating, Engraving (except Jewelry and Silverware), and Allied Services to Manufacturers, Metal coating and allied services, Metal Coating, Metal industries, Human resource management, Metal industry, Metal coating processes, Rogers Galvanizing Co.

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