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健康保险、人寿保险和残疾保险判例法的最新发展。

Recent developments in health insurance, life insurance, and disability insurance case law.

作者信息

Hasman Joseph J, Chittenden William A, Doolin Elizabeth G, Wall Julie F

机构信息

Chittenden, Murday & Novotny LLC, Chicago, USA.

出版信息

Tort Trial Insur Pract Law J. 2008 Spring;43(3):473-517.

PMID:18828249
Abstract

This survey reviews significant state and federal court decisions from 2006 and 2007 involving health, life, and disability insurance. Also reviewed is a June 2008 Supreme Court decision in the disability insurance realm, affirming that a conflict of interest exists when an ERISA plan sponsor or insurer fulfills the dual role of determining plan benefits and paying those benefits but noting that the conflict is merely one factor in considering the legality of benefit denials. In addition, this years' survey includes compelling decisions in the life and health arena, including cases addressing statutory penalties and mandated benefits, as well as some ERISA decisions of note. This year, the Texas Supreme Court held that Texas's most recent version of the prompt payment statute abolished the common law interpleader exception and allowed the prevailing adverse claimant in an interpleader action filed beyond the sixty-day statutory period to recover statutory interest and attorney fees from the insurer. Meanwhile, the Court of Appeals of New York upheld the constitutionality of a statute mandating coverage for contraceptives in those employer-sponsored health plans that offer prescription drug coverage, including those plans sponsored by faith-based social service organizations. In the ERISA context, litigants continue to fight over the standard of review with varying results. In a unique assault on the arbitrary and capricious standard of review, the Fourth Circuit found that an ERISA plan abused its discretion when it failed to apply the doctrine of contra proferentem to construe ambiguous plan terms against itself. In more hopeful news for plan insurers, the Tenth Circuit held that claimants are not entitled to review and rebut medical opinions generated during the administrative appeal of a claim denial before a final decision is reached unless such reports contain new factual information.

摘要

本调查回顾了2006年和2007年涉及健康、人寿和残疾保险的重要州法院和联邦法院判决。同时也回顾了2008年6月最高法院在残疾保险领域的一项判决,该判决确认,当《雇员退休收入保障法》(ERISA)计划主办方或保险公司同时履行确定计划福利和支付这些福利的双重职责时,存在利益冲突,但指出这种冲突只是考虑福利拒绝合法性的一个因素。此外,今年的调查还包括生命与健康领域引人注目的判决,包括涉及法定处罚和强制福利的案件,以及一些值得关注的ERISA判决。今年,得克萨斯州最高法院裁定,得克萨斯州最新版本的即时支付法规废除了普通法的互争权利诉讼例外规定,并允许在法定六十天期限之后提起的互争权利诉讼中胜诉的不利索赔人从保险公司获得法定利息和律师费。与此同时,纽约上诉法院维持了一项法规的合宪性,该法规要求在提供处方药保险的雇主赞助健康计划中,包括由基于信仰的社会服务组织赞助的计划,必须涵盖避孕措施。在ERISA背景下,诉讼当事人继续就审查标准展开争论,结果各异。在对任意和反复无常的审查标准的一次独特抨击 中,第四巡回上诉法院认定,当一项ERISA计划未能适用不利于提供者的原则来对模棱两可的计划条款作出对其自身不利的解释时,该计划滥用了其酌处权。对计划保险公司来说更值得欣慰的消息是,第十巡回上诉法院裁定,除非此类报告包含新的事实信息,否则在最终决定作出之前,索赔人无权在对索赔拒绝的行政上诉过程中审查和反驳所产生的医学意见。

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