Federal Court Ruled For Hospital: 106 ER Claims under ERISA, PPACA, EMTALA & Out-of-Network

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ERISAclaim.com Offers New Executive Webinars To Examine The Latest Federal Court Decision On Feb 9, 2012 For The Hospital, Alleging That 106 Emergency Room Claims Were Wrongly Denied In Violation Of ERISA, PPACA & EMTALA. This Court Decision Is Extremely Important For Every Hospital.

ERISA now provides payment for even non-covered services as a result of an insurer’s fiduciary ERISA violation.

ERISAclaim.com offers new executive webinars to examine the latest federal court decision on Feb 9, 2012 for the hospital, alleging that 106 emergency room claims were wrongly denied in violation of ERISA, PPACA & EMTALA. This court decision is extremely important for every hospital across the nation. The court outlined a new ERISA roadmap for every hospital with all ER claims. More importantly, the federal court ruled for the hospital for its right to sue for not only benefits payment for the policy covered services under ERISA, also for the damages as a result of fiduciary breach under ERISA, even for policy non-covered services, as the make whole surcharge pursuant to the new Supreme Court decision in CIGNA v. Amara (No. 09–804) on May 16, 2011. The monetary relief for the policy excluded services, or extra-contractual damage, was never available under ERISA over the past 36 years until last year.

“Every hospital must love or comply with ERISA, the federal law governing all private health plans. ERISA now provides payment even for non-covered services as a result of an insurer’s fiduciary ERISA violation,” said Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

The court case info: North Cypress Medical Center Operating Co, Ltd v. Principal Life Insurance Company, Civil Action No. H-09-2185, United States District Court, S.D. Texas, Houston Division. February 9, 2012.

“The federal court basically says the hospital had good ERISA assignments for 106 patients, it may simultaneously sue for policy benefits or damages, if not covered, as a result of insurer’s fiduciary violation of ERISA regardless of policy exclusion,” said Dr. Zhou.

According to the Court document, the following is the case factual background in part:

"The plaintiffs provided medical care in their ER to the 106 patients who are insured by and/or subscribers to the defendant’s health insurance policies and/or plans, but the plaintiffs are not within the defendant’s network of preferred providers. The plaintiffs also qualify as a “participating hospital” under the requirements of the Federal Emergency Medical Treatment and Active Labor Act (“EMTALA”), which requires them to provide appropriate medical screening in their ER facilities to any patient who requests examination, notwithstanding their ability to pay.”

According to the Court document, the following is the plaintiff hospital’s argument:

“The plaintiffs contend that even though they were out-of-network providers, the defendant should have paid the 106 claims at in-network levels because they were Medical Emergencies. The plaintiffs allege that the defendant knowingly and intentionally violated federal law by arbitrarily reducing the amounts it was supposed to pay the plaintiffs for the contested ER claims. The plaintiffs seek to recover benefits under ERISA § 502(a)(1)(B), or alternatively ERISA § 502(a)(3). Claiming that all conditions precedent have been met, they assert counts for: (1) failure to comply with the group policies/plans; (2) breach of fiduciary duties; (3) failure to provide a full and fair review; (4) claims procedure violations; (5) a request for information; (6) improper usual and customary rate (“UCR”) calculations; (7) relief under Federal Rule of Civil Procedure 54(c).”

According to the Court document, the following is the defendant insurer’s argument:

“The defendant contends that these 106 claims were for “Emergency Room Services” rather than “Medical Emergencies,” and that therefore they were payable at the non-preferred levels of 110% of the Medicare/cost basis. It asserts that it paid the claims correctly in accordance with the terms of its policies and plans, and that it is not liable for charges for which the patients themselves are not liable. It claims that the plaintiffs lack standing to bring their claims and that they failed to exhaust their administrative remedies. It maintains that the plaintiffs must show that the defendant abused its discretion to recover under ERISA § 502(a)(1)(B), and that they may not seek to recover simultaneously under ERISA Sections 502(a)(1)(B) and 502(a)(3). It argues that the plaintiffs do not have viable claims for the defendant’s alleged: (1) policy/plan violations; (2) failure to fully and fairly review its policies/plans; (3) breach of a discount agreement; and (4) breach of fiduciary duties. Lastly, it avers that the Patient Protection Affordable Care Act (“PPACA”) is inapplicable to most of the 106 claims, and that certain of its payment methods are proprietary information.”

The Court decided for the hospital in part:

“In order to further clarify this confusing conglomeration of disputes, the Court sets the following parameters: (1) the plaintiffs have standing to bring this case; (2) the plaintiffs may argue for relief under ERISA § 502(a)(1)(B), or in the alternative, ERISA § 502(a)(3), but not both; (3) the plaintiffs do not have to prove exhaustion of administrative remedies for each underlying claim; (4) the parties’ next submissions to the Court will argue only whether/when “Medical Emergency” and “Emergency Room Services” are mutually exclusive terms, and whether the out-of-network plaintiffs are entitled to preferred provider rates for each of the 106 ER claims. The Court will not address the competing methods of calculating appropriate payments until it determines whether it needs to do so after reading the parties’ next submissions.”

To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.


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