Managed Care Litigation Update Volume 62: August 15, 2016

• Citation: Vol. 62
• Publication year: 2016

Newsworthy

The mirror image of the ACA and rate increases. http://www.nytimes.com/2016/08/15/us/politics/health-insurers-use-process-intended-to-curb-rate-increases-to-justify-them.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=2&pgtype=sectionfront

Mass. insurer Minuteman Health sues U.S. Health and Human Services over risk adjustment. http://www.bizjournals.com/boston/blog/mass roundup/2016/07/massachusetts-insurer-sues-feds-over-obamacare.html?ana=RSS%26s=article search

Also Community Health Options. http://www.pressherald.com/2016/08/10/health-insurance-co-op-suing-federal-government-for-23-million/

BCBS TX may cover transgender surgery. See also case against Aetna alleging improper denial of breast implants following gender transition, MCLU Vol. 45. http://www.mrt.com/health_and_wellness/stories/article_07e1eb8a-5900-11e6-b152-73885d096cee.html

Recently filed actions

Benjamin Levine v. CIGNA Health and Life Insurance Company, et al., U.S.D.C. N.D. CA, Doc. No. 3:16-cv-04404-LB, (filed Aug. 4, 2016). Member seeks recovery of benefits associated with an allograft ACL reconstruction surgery on his knee, which required an allograft tissue implant. A portion of the $26,465.00 claim attributable to the allograft tissue implant was denied on the basis that "[the] implant was not medically necessary and therefore excluded from coverage ... "

John H., et al. v. United Healthcare, United Behavioral Health, et al., U.S.D.C. D. UT, Doc. No. 1:16-cv-00110-DBP, (filed Aug. 4, 2016). Parents seek recovery of benefits, in an amount exceeding $120,000, associated with child's mental health conditions and treatment at Aspen Institute and Elevations Residential Treatment Center (f/k/a Island View Residential Treatment Center) in Utah. "Coverage was not available [for Aspen] based on a review of the terms of the Plan, the 'UBH Coverage Determination Guidelines for the Residential Treatment of Major Depression/Mood Disorder NOS,' and medical records submitted." Claims were paid for approx. 11 days at Elevations, thereafter denied because inter alia "there was no imminent risk of the need for acute inpatient care."

Jessica Glover, et al. v. Health Care Service Corporation, et al., U.S.D.C. W.D. OK, Doc. No. 5:16-cv-00884-C, (filed Aug. 4, 2016). Removed action in which parents seeks recovery of benefits associated with air ambulance transport of an infant, born via...