Managed Care Litigation Update Volume 216: January 15, 2023

• Jurisdiction: Texas,United States,Federal
• Publication year: 2023
• Citation: Vol. 216

NEWSWORTHY

A unanimous Texas Supreme Court affirmed the Court of Appeal's decision, holding that three sections of the Texas Insurance Code, referred to as the Emergency Care Statutes (requiring a health insurance company to pay non-network physicians for emergency care at the usual and customary rate) do not authorize a private right of action by physicians against insurers for payment of claims that accrued prior to January 2020. The Texas Supreme Court also held that the physician-plaintiffs' claims for recovery in quantum meruit and for unfair settlement practices fail as a matter of law. Tex. Med. Res., LLP v. Molina Healthcare of Tex., Inc., No. 21-0291, 2023 WL 176287 (Tex. Jan. 13, 2023). DISCLOSURE - I represent the Respondent, Molina Healthcare of Texas, Inc.

District court dismisses, in part, putative class action claims challenging Aetna's use of Clinical Policy Bulletins ("CPBs") in determining medical necessity for purposes of ERISA policies, holding that plaintiff could only challenge the use of CPBs with respect to the rehabilitation therapy denied to the named plaintiff. Dennis E. Curtis, et al. v. Aetna Life Insurance Company, USDC D. CT, No. 3:19-cv-1579-MPS, 2023 WL 34662, (Doc. 74, filed Jan. 4, 2023). Previously reported in MCLU Vol. 138.

District court dismisses implied contract claims against ERISA plans where provider alleged the plans failed to pay the Multiplan contract rate for services to beneficiaries whose insurance cards contained the Multiplan logo. Atlantic Neurosurgical Specialists, P.A. v. [ ], Connecticut General Life Insurance Company, et al., USDC SD NY, No. 20-cv-10685, 2023 WL 160084, (Doc. 98, filed Jan. 11, 2023). Previously reported at MCLU Vol. 167.

RECENTLY FILED ACTIONS

Sunrise Hospital and Medical Center, LLC v. Blue Cross and Blue Shield of Michigan, U.S.D.C. D. NV, Doc. No. 2:23-cv-8-GMN-VCF, (filed Jan. 3, 2023). Hospital seeks benefits and alleges underpayment associated with three members. Plaintiff asserts it is in network with the host BCBS plan but that the home plan has not followed that provider agreement.

Gary Sadeghi, et al. v. Health Care Service Corporation, U.S.D.C. W.D. OK, Doc. No. 5:23-cv-7-G, (filed Jan. 4, 2023). Former member seeks approximately $35,000 in ERISA benefits associated with a 4-month hospitalization in Brazil where plaintiff alleges the claims for reimbursement through the Blue Cross Global Claims program were "effectively denied" when the plan cancelled the policy.

Emily...