Claim Procedures

News & Analysis as of

Medical Claims and Nursing Homes:  The Struggle to Apply the Protections of Ohio Rev. Code § 2305.113 to Long Term Care Facilities

Due to the restrictions and limitations placed on plaintiffs filing “medical claims”—i.e., a one-year statute of limitations, filing an affidavit of merit, and caps on certain damages—an important battle has arisen regarding...more

Grower Security and Payment Protection Legislation Awaits Senate Approval

On May 5, the Senate Commerce Committee approved Senate Bills 899 and 900. The legislation would strengthen Michigan's Grain Dealer's Act and Farm Produce Insurance Act should a licensed grain dealer end up insolvent or...more

Medicare Launches Home Health Pre-Claim Review Demonstration in Five States

The Centers for Medicare and Medicaid Services (CMS) recently announced it will implement a pre-claim review demonstration for home health services. The three-year demonstration will apply to home health services performed in...more

Second Circuit Applies Stricter Rules for a Plan Administrator’s Noncompliance with Benefit Claims Regulations

In Depth - On April 12, 2016, the US Court of Appeals for the Second Circuit in Halo v. Yale Health Plan, 2016 WL 1426291 (2d Cir. Apr. 12, 2016), addressed various issues that could arise during a plan administrator’s...more

OMHA Expands Settlement Conference Facilitation Program to Part A Appeals: 10 Things to Know

On Feb. 25, 2016, the Office of Medicare Hearings and Appeals (OMHA) conducted a teleconference to address Phase III of the Settlement Conference Facilitation (SCF) project, which also became effective on Feb. 25, 2016. SCF,...more

Too Little, Too Late: The Harsh Bright Line of Suit Limitation Provisions

Approximately twenty percent of Americans have been classified as chronic procrastinators, which means one in five policyholders faces a potential problem when suing for coverage. While the statute of limitations for breach...more

DOL Proposes More Robust Claims Procedures for ERISA Disability Claims

The Department of Labor (DOL) recently issued proposed regulations that would strengthen claim procedures for disability claims made under retirement and welfare plans subject to the Employee Retirement Income Security Act of...more

DOL Tightens Disability Claim Processing Rules

“Isn’t this an ACA blog?” Yes, it is. “So, why are you writing about disability plan administration?” Because they said so. The preamble to the proposed rules explains – Inasmuch as disability and lost earnings can be sources...more

Natural Disasters in Latin America: Reinsurance Issues

According to initial reports, Hurricane Patricia didn't end up causing nearly the damage that the world’s most powerful hurricane could have caused. It is a good reminder, however, for reinsurers of how sudden and...more

A Claim Is In the House: What To Do

Our clients take very seriously the legal duty to insure or self-insure for workers' compensation. In the wake of reportage that was critical of everybody involved in the noninsured phenomenon, employers are aware that civil...more

Seventh Circuit Reverses Injunctive Relief for Chiropractic Association

On October 1, 2015, the United States Court of Appeals for the Seventh Circuit reversed what was previously regarded as a victory for the Pennsylvania Chiropractic Association. The case, Pennsylvania Chiropractic Association...more

Project In(Site): Legal Developments Impacting Construction & Government Contract Industries

Welcome to the inaugural issue of Project In(Site), Seyfarth’s Construction and Government Contracts practice groups’ publication focusing on decisions or other items of interest for construction and government contract...more

Catching Up To Insurers’ Use of Big Data

Various groups within the NAIC are beginning to study the way in which insurers are using big data. On the property and casualty front, the Market Regulation (D) (Market Reg) Committee is reviewing the use of big data in...more

The CHRO Complaint Process Needs A Reboot

Lately, I’ve been hearing a lot of complaints about the Connecticut Commission on Human Rights & Opportunities from both attorneys and clients. And I’ve come to one conclusion: The CHRO Complaint Procedure needs a...more

ERISA: When Does A Claimant Get To “Augment” The Administrative Record?

You already know that judicial review of ERISA claims generally will be limited to the administrative record considered by the claim administrator. But the courts will allow claimants to augment the record if ERISA...more

New Restrictions: CMS Limits Scope of Review on Redeterminations and Reconsiderations for Certain Audit Appeals

On August 13, 2015, the Centers for Medicare & Medicaid Services (CMS) issued instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for...more

HUD’s Proposal to Terminate FHA Insurance Policies Could Terminate the FHA Program

If there is anything that galls servicers of government-insured loans, it is the forfeiture or curtailment of all accrued interest from mortgage insurance claims resulting from the failure to foreclose fast enough within...more

A Primer on Insurance Underwriting in China

China is one of the largest and fastest-growing insurance markets in the world. It provides the global insurance and reinsurance industry with tremendous opportunities but also presents challenges with its unique legal and...more

Seeing the Finish Line: Courts Increasingly Exempt Claims-Made Policies from the Notice Prejudice Rule

In a majority of jurisdictions, the “notice-prejudice rule” provides that an insurer may not deny a claim on grounds of late notice without demonstrating prejudice. The rule is statutory in some states and judicially crafted...more

Bad Faith Sentinel - April 2015

In This Issue: - En Banc Mississippi Court of Appeals Affirms Summary Judgment for Insurer, Adjuster and Employer on Bad Faith Claims Arising from Denial of Coverage and Benefits for Work-Related Injury -...more

Cooperate, Or Else

Cooperation is key. Or so says the 10th Circuit at least, in addressing an appeal from a district court’s dismissal of an insured’s action in which he failed to cooperate with his insurer’s claim investigation. The 10th...more

Claims Administration and Handling in Mass Tort Cases: Lessons from Deepwater Horizon

In mass casualty and toxic tort litigation, an effective means of providing prompt and efficient compensation to victims can benefit all stakeholders. Claimants receive prompt payment for lost property or business expenses,...more

2014 Hail-Related Insurance Litigation Year In Review

The number of lawsuits arising from hail-damage claims to residential and commercial properties has increased dramatically over the past few years. Indeed, since 2012, hundreds of lawsuits alleging underpayment of...more

Procedural Errors Don’t Alter Standard of Review In ERISA Claim for Benefits

The Ninth Circuit recently held that where an ERISA plan provides the plan administrator discretionary authority to determine benefit claims, procedural violations that occur during the course of the administrative claims...more

DOL’s New Audit Focus? Health Plan Claims and Appeals and Hard to Value Assets

In recent talks and appearances, representatives of the U.S. Department of Labor have issued a warning about new areas of focus of DOL audits and enforcement actions. While there are a number of different enforcement...more

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