In 2014, a unanimous 3-judge panel of the Ninth Circuit ruled in favor of Creitz & Serebin's clients in their appeal from the District Court of Arizona. Spinedex v. United, 770 F.3d 1282 (9th Cir. 2014), cert. denied, 136 S. Ct. 317 (2015). Among the issues that the Ninth Circuit addressed were these:
- Where a healthcare provider sues for ERISA-regulated benefits pursuant to an assignment from the patient/plan-beneficiary, there is no requirement for the provider to send a balance bill to the patient in order for the provider to have standing to sue under Article III of the U.S. Constitution. It seems like a simple and obvious point, but a number of courts had gone sideways on this question and the Ninth Circuit got it right.
- The Ninth Circuit reemphasized its earlier holding from Harlick v. Blue Shield of California, which had held that an ERISA claims administrator waives (and therefore cannot assert in litigation) any defenses to the payment of benefits that it failed to assert during the administrative process.
- The Claims Regulation propounded by the United States Secretary of Labor has long provided that the failure of a claims administrator to adhere to the regulations requirements results in "deemed denial" -- i.e., the participant can go straight to court if the administrator fails to follow the regulation. The Ninth Circuit held that administrators' failure to comply with this regulation can be no more than de minimis, effectively requiring strict compliance with the regulation (the insurer had sought a "substantial compliance" standard that would have severely disadvantaged participants and beneficiaries).
- The Ninth Circuit expanded on its earlier unanimous en banc holding in my case Cyr v. Reliance, to hold that proper party defendants under ERISA section 502(a)(1)(B) also include claims administrators. (I posted previously about this case when the Ninth Circuit issued its opinion).
On that last issue, the insurer sought certiori from the United States Supreme Court, which the Supreme Court denied on October 13, 2015. Spinedex v. United, 770 F.3d 1282 (9th Cir. 2014), cert. denied, 136 S. Ct. 317 (2015).
Along with Cyr, was another landmark ERISA decision from the Ninth Circuit that Creitz & Serebin secured along with our co-counsel, Joe Garofolo. Here's a link to the Ninth Circuit's Decision.
If you find yourself struggling with your ERISA plan's administrator or insurer over your benefits (pension, disability, health, or otherwise), let us see if we can help.
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