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First Circuit Holds That 'Full and Fair Review' of Claim Denial Requires Disclosure of Medical Reports Generated During Appeal

"ERISA ... requires that plan fiduciaries employ a 'full and fair' claims procedure for reviewing benefit claims. But courts have grappled with ... whether this requires that a plan participant or beneficiary making a claim for benefits be given an opportunity to review and respond to medical reports before they are relied upon by the claims administrator to deny the claim. The answer from the First Circuit is a resounding 'yes,' regardless of what version of the [DOL's] claims regulation applies." [Jette v. United of Omaha Life Ins. Co., No. 20-1713 (1st Cir. Nov. 10, 2021)]

Third Circuit: Irregular Request by Claims Administrator for an Outside Medical Report Used to Deny Disability Claim Was Abuse of Discretion

"[T]he court found that [Reliance Standard Life's (RSL's)] decision to request the first IME was of unusual timing and impetus since it [had] just certified [the individual's] disability.... Though a fiduciary can seek an IME at appropriate stages of the claims process, 'the timing of and professed need for the IME were irregular.' The court found the second procedural anomaly to be RSL's request for two peer reviews after it decided to overturn the initial decision." [Fulton Financial Corporation Employee Benefit Plan; Reliance Standard Life Insurance Company, No. 19-3855 (3d Cir. Nov. 26, 2021)]

Court Finds No FMLA Retaliation Claim When Employee Submitted Conflicting Medical Reports

"After investigating the circumstances and reviewing Shipton's medical documentation, BGE believed he had been misusing leave.... Shipton's conflicting paperwork and BGE's investigation reasonably gave rise to an honest belief on the part of the employer at the time of his firing that Shipton was misusing FMLA leave -- even if that later turned out not to be the case. Accordingly, the court found in favor of BGE and against Shipton on his FMLA retaliation claim." [Shipton v. Baltimore Gas and Elec. Co., No. 23-1360 (4th Cir. Jul. 31, 2024)]

The Medical Loss Report: Fiddling While Rome Burns

"The Wall Street Journal, citing a Goldman analysis, is reporting that Aetna will be paying out $177 million in rebates. But Aetna has $11 billion in premium so that's only a 1.6% rebate. UnitedHealth will be paying out $307 [m]illion but that is only 1% of its $28.8 billion in premium. Wellpoint will pay out $94 million in rebates but that is only .28% of its premium for the year. The average cost of employer-provided family health insurance is now about $13,000 per year. A family rebate of perhaps $200 will amount to only about 1.5% of premium for the relatively few people who will even get one."

Text of CCIIO Technical Guidance 2015-0002: Q&A on the Medical Loss Ratio Reporting and Rebate Requirements for the 2014 MLR Reporting Year (PDF)

"The purpose of this bulletin is to provide guidance regarding limited circumstances under which a health insurance issuer will not be treated as out of compliance with the regulatory deadline for 2014 reporting year MLR rebate distribution to policyholders and enrollees under section 2718 of the Public Health Service Act (PHS Act) and 45 CFR Section 158.240. These limited circumstances are if the issuer [1] pays the rebates no later than October 30, 2015, and [2] timely submitted its 2014 MLR Reporting Form and Risk Corridors Plan-Level Data Form but was required to resubmit those forms in September 2015."

Comment Letter by the Medical Loss Ratio Regulation Work Group of the American Academy of Actuaries, to HHS on MLR Reporting Aspects of Proposed Contraceptive Mandate Rules (PDF)

"[I]n situations in which ['zero premium contraceptive-only'] policies are issued to individuals whose underlying comprehensive medical coverage is provided via a self-funded group health plan ..., the issuer (or an affiliate) would be eligible to receive adjustments to any federally facilitated exchange (FFE) user fees it might owe ... All else being equal, a lower level of FFE user fees would lead to higher reported premiums for MLR purposes, a lower reported MLR value, and a potentially higher level of customer rebates."

Text of CCIIO Technical Guidance 2012-004: Questions and Answers on the Medical Loss Ratio Reporting Requirements (PDF)

Issued May 30, 2012. "[Question:] Will CMS grant extensions of the June 1, 2012 deadline for issuers to submit their MLR annual report or the August 1, 2012 deadline for issuers to provide rebates for the 2011 MLR reporting year? [Answer:] No. 45 CFR Section 158.110(b) establishes 'June 1 of the year following the end of an MLR reporting year' as the date by which an issuer must submit the MLR report, and 45 CFR Section 158.240(d) establishes 'August 1 following the end of the MLR reporting year' as the date by which an issuer must provide any rebate owing. Therefore, because the MLR regulation does not provide for extensions to either deadline, no extensions will be granted for these deadlines."

Claim Denial Letter Is Only as Good as the Analysis Contained in the Medical Examiner's Report

"Don't rely on the mere conclusions by the independent reviewer and inform your independent medical reviewer that the reasons for the conclusions are as important as the conclusions themselves. That is because ... your denial letter is only as good as the analysis/reasons stated in the IME report." [Westfall v. Liberty Life Assurance Co. of Boston, No. 16-2921 (N.D. Ohio Feb. 28, 2018)]

Report by Joint Committee on Taxation on the Medical Savings Account Provisions in H.R. 4250

"On July 23, 1998, the House Committee on Rules is scheduled to consider a rule for H.R. 4250, the 'Patient Protection Act of 1998.' This [report] describes certain proposals to be offered as an amendment to the bill. These proposals are intended to provide revenue offsets to the provisions of section 3201 of the bill, relating to expansion of the availability of medical savings accounts." [JCX-56-98 July 23, 1998]

Text of CMS Question and Answer Regarding the Medical Loss Ratio Reporting and Rebate Requirements (PDF)

"Issuers may exclude ACA assessments or fees from MLR calculations for a reporting year only if such assessments or fees were incurred in that reporting year. Issuers may not exclude ACA assessments or fees they expect to incur in future MLR reporting years." [CCIIO Technical Guidance (CCIIO 2013—0003)]