"This case factual story is plain and simple but the outcome is extremely atypical and unprecedented."
Hanover Park, IL (PRWEB) June 17, 2013
On June 13, 2013, citing a recent Supreme Court decision, the 7th Cir. Court rules that Supreme Court sets new insurance verification laws under ERISA: $77,974 in money damage for a patient when her health plan falsely verified for coverage when none existed in ERISA fiduciary breach. A plan fiduciary is liable for money damages, as an equitable relief under ERISA, in failing to provide accurate and complete coverage information and/or means to obtain authoritative and binding information, when specifically requested by a patient or provider prior to the treatment.
This is the first court decision in the 37 year ERISA history that provides a patient with money damage protection against a plan’s false coverage verification in violation of ERISA, even no true coverage existed under the plan. This Supreme Court decision, as interpreted by the 7th Cir. Court on June 13, 2013, protects both in-network and out-of-network patients and providers, according to Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA appeals and compliance.
ERISAclaim.com offers new seminars to demystify why and how these new court decisions will immediately and profoundly change entire healthcare industry compliance and litigation in insurance coverage verification and/or precertification for both in-network and out-of-network patients, providers, health plans and managed care TPA’s; how to comply with ERISA by health plans to avoid money damage ERISA surcharge or how to obtain money damage reimbursement even without a plan coverage if a plan breached its ERISA fiduciary duties and harmed a patient, as prescribed by the Supreme Court.
Case info: Deborah Kenseth v. Dean Health Plan, Inc., In the United States Court of Appeals for the Seventh Circuit, Case No. 11-1560, Decided June 13, 2013.
This case factual story is plain and simple but the outcome is extremely atypical and unprecedented.
Plaintiff patient called the health plan for coverage verification and pre-approval for her gastric bypass surgery. The plan told her it would cover the procedure subject to a $300 co-payment. One day after her surgery, the plan decided to deny coverage for the surgery and all associated services based on the exclusion for services related to a non-covered benefit or service, namely, surgical treatment of morbid obesity, according to the court documents.
After exhausting all her appeal remedies, she sued the plan in federal court for ERISA fiduciary breach and reimbursement of surgical costs in $77,974. The district court twice ruled against her and she twice appealed to the 7th Cir. Court, losing the first one but winning the second appeal, due to a recent Supreme Court decision in Cigna Corp. v. Amara, 131 S. Ct. 1866 (2011, Case No. 09–804), clarifying the relief available for a breach of fiduciary duty in an action under the ERISA, according to the court document.
The 7th Cir. Court concludes: “Cigna substantially changes our understanding of the equitable relief available under section 1132(a)(3). Kenseth has argued for make-whole relief in the form of monetary compensation for a breach of fiduciary duty from the start of this litigation. We now know that, in appropriate circumstances, that relief is available under section 1132(a)(3). See Cigna, 131 S. Ct. at 1881-82”, according to the court document.
In addition to the new ERISA money damage surcharge remedies available under ERISA, the 7th Cir. Court also clarifies the plan’s fiduciary duties or obligations to provide accurate and complete information and documents when a patient or provider inquiries about her insurance coverage, regardless of in-network or out-of-network providers, says Dr. Zhou.
The 7th Cir. Court clarifies: “we have previously held that an insurer has an affirmative obligation to provide accurate and complete information when a beneficiary inquires about her insurance coverage…….The most important way in which the fiduciary complies with its duty of care is to provide accurate and complete written explanations of the benefits available to plan participants and beneficiaries……But if the documents are ambiguous or incomplete on a recurring topic, a fiduciary may be liable for mistakes that representatives make in answering questions on that subject”, according to the court document.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
Located in a Chicago suburb in Illinois, for over 13 years, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.
For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.