Claims Procedures

News & Analysis as of

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

Statute of Limitations for Submitting a Claim Against CIGA

Statute of Limitations for Submitting a Claim Against CIGA - Court Of Appeal, First Appellate District (September 17, 2014) - The California Insurance Guarantee Association (“CIGA”) has a statutory duty to pay...more

Insurer Sues Department of Insurance Over Multi-Million Dollar Penalty

In suing the California Insurance Commissioner on July 10, 2014, PacifiCare Life Insurance Company sought a writ of mandamus ordering the Commissioner to set aside his Decision and Order imposing a record $173 million penalty...more

CMS Waves Partial White Flag in Appeals of Payment Status Denials

For the last several years, hospitals, on the one hand, and the Centers for Medicare and Medicaid Services and its contractors (collectively, CMS), on the other, have been engaged in a spirited dispute over claims denials for...more

Start Spreading the News: With National Union v. TransCanada, New York Prepares to Broadcast Communications with Coverage...

The final opinion of a New York appellate court in National Union Fire Ins. Co. of Pittsburgh v. TransCanada Energy USA, Inc., 119 A.D.3d 492 (2014), is only three paragraphs long, but it raises a host of questions about how,...more

New Jersey Court Holds that Six-Month Delay in Providing Notice to Carrier Bars Coverage under Claims-Made Policy

Policyholders often are cautioned to provide notice of a claim to their insurance carrier as soon as possible to avoid the risk that the carrier will deny coverage due to late notice. A recent court decision in New Jersey...more

It is Always Good to Follow the Plan’s Claims Procedure in Denying a Claim – Part 2

Some months ago I blogged about an Eighth Circuit Court of Appeals decision involving high ranking executives participating in a company’s long term incentive plan where the executives won their suit under the plan, at least...more

Arizona’s Notice Of Claim Statute – Jumping Through Hoops When Suing State Government Or Its Agencies Or Political Subdivisions

For 20 years, the State of Arizona, its agencies and political subdivisions have held a secret weapon to thwart claims made against them for everything from breach of employment contracts to gross negligence in providing...more

Claims Against Failed Banks Must Go Through the FDIC’s Administrative Claims Process

As described in a previous post, the Financial Institutions Reform, Recovery, and Enforcement Act (“FIRREA”) requires that anyone with a claim against a failed bank must file a claim with the FDIC within 90 days of being...more

Petiioner Can Submit Supplemental Information Challenging Additional Claims

In Callidus Software Inc. v. Versata Software, Inc., CBM2013-00052, Paper 26, CBM2013-00053, Paper 21, CBM2013-00054, Paper 24 (March 28, 2014), Petitioner sought to file supplemental information to challenge dependent claims...more

The FDIC’s Administrative Claims Process for Failed Banks

Enacted by Congress after the Savings and Loan Crisis of the 1980s, the Financial Institutions Reform, Recovery, and Enforcement Act (“FIRREA”) gives the FDIC sweeping authority to resolve the problems posed by a failed...more

Homeowners Beware: Fraud in Claims Process Can Lead to Judicial Sanctions in Bad Faith Action

A federal court for the Southern District of Texas has sanctioned a pro se litigant for making fraudulent misrepresentations to his homeowner’s insurer following a fire, and for bringing a bad faith action against the...more

ERISA: Incorrect Statements During Claims Process Do Not Render ERISA Inapplicable

PROBLEM: During the claim process your claims administrator mistakenly tells the claimant that the ERISA-governed plan is NOT governed by ERISA. Uh oh. Do you lose ERISA as the governing law over the policy and claim?...more

Illinois Court Addresses Distinction Between Claim and Potential Claim

In its recent decision in Lexington Ins. Co. v. Horace Mann Ins. Co., 2013 U.S. Dist. LEXIS 127544 (N.D. Ill. Sept. 4, 2013), the United States District Court for the Northern District of Illinois had occasion to consider...more

An Insurer Cannot Claim That It Was Unaware of Claims Handling Statutes As A Defense To Bad Faith

The South Dakota Supreme Court in Bertelsen v. Allstate Insurance Co., 833 N.W.2d 545, No. 26442 (June 12, 2013) (1) held that an insurer cannot avoid bad faith liability by claiming it did not know about controlling claims...more

Understanding the Surety Bond Claims Process

The following guest post is from Sara Aisenberg, Director of Educational Outreach at SuretyBonds.com, a nationwide surety bond producer that helps contractors fulfill their bonding requirements....more

Ordering/Referring Phase 2 Begins May 1st - Claims Will Be Denied

In an April 24, 2009 transmittal, CMS announced a two-phase claims editing expansion designed to allow verification that the physician or non-physician practitioner (NPP) listed as the ordering/referring provider on a...more

Second Circuit Narrows ERISA Exhaustion Requirement When Plan Document Is Ambiguous on Need to Follow Claims Procedures

The U.S. Court of Appeals for the Second Circuit’s holding in Kirkendall v. Halliburton, Inc. reaffirms that a benefit plan’s claims procedures must be drafted clearly and in language to be understood by a reasonable...more

18 Results
|
View per page
Page: of 1