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Learn about how ERISA Laws could positively and negatively be affecting your out-of-network practice
On June 6, 2012 the U.S. District Court for the Northern District of New York declined to dismiss key elements of an action for reimbursement of medical costs.
After “liberally construing” the proposed amended complaint, the court found plaintiffs stated three cognizable claims under the Employee Retirement Income Security Act (ERISA).
Plaintiffs Karen Haag and Dr. Dimitri Koumanis sued defendant MVP Health Care asserting seven state law claims related to MVP's alleged failure to comply with benefits claim procedures and refusal to pay the full cost of Haag's breast reconstruction surgery.
Koumanis had submitted a claim for $38,500 for performing the breast reconstruction surgery and received payment of less than $3,000.
The district court first addressed the issue of standing sua sponte and dismissed Haag as a plaintiff because she assigned her right to recover benefits to Koumanis.
However, the court rejected MVP Health Care’s motion to be dismissed as a defendant because even though Haag’s ERISA-covered employee health plan designated The College of Saint Rose as the putative plan administrator, it appeared as if MVP might have made the final benefits determination.
After finding that Koumanis exhausted his administrative remedies by virtue of MVP’s failure to follow reasonable claims procedures, the court turned to the merits of the claims.
(1) for failure to provide proper notification of an adverse benefit determination, and
(2) for payment of full benefits due under the plan.
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