Category: Blog

Limits to Bad Faith Discovery in Illinois?

May 17, 2016 | Blog |

Zagorski v. Allstate Insurance Company, 2016 IL App (5th) 140056 (May 16, 2016) St. Clair Co. (CATES) Affirmed in part, reversed in part, and vacated in part; remanded with directions.  (WELCH and GOLDENHERSH, concurring.) Plaintiffs filed suit against their insurer, Allstate Insurance Company, alleging vexatious breach of contract and common law fraud, under Section 155 of Insurance Code, in handling of their homeowners’ insurance claim.  Defendant insurer argued that the trial court abused its discretion in permitting the Plaintiffs to discover the number of times in the last five years that Allstate (a) was cited by the Illinois Department of […]

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How Will the Court Review My Long Term Disability Case?

May 12, 2016 | Blog |

In the long anticipated ruling in Fontaine v. Metropolitan Life Ins. Co., No. 14-1984, 2015 U.S. App. (7th Cir. Sept. 4, 2015), the Seventh Circuit affirmed that Illinois’s anti-discretionary clause regulation in 50 Ill. Admin. Code §2001.3, that prohibits discretionary clauses in insured employee benefits plans offered or issued in Illinois, was outside the scope of the preemption power of the Employee Retirement Income Security Act of 1974 (ERISA).  The decision makes clear that the judicial standard of review for all benefits determinations under ERISA plans offered or issued in Illinois is de novo. This ruling confirms a trend of […]

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Social Security Agency Rules Proposal

Mar 21, 2016 | Blog |

The  American Bar Association’s House of Delegates recently approved Resolution 106B. The Resolution proposes various reforms to the rulemaking provisions of the Administrative Procedure Act (“APA”), many of which embrace principles endorsed in past Administrative Conference of the United States recommendations.  This project identifies points of overlap, and offers the Conference’s views on non-overlapping portions of the Resolution. Issuing a Statement on ABA Resolution 106B offers the Conference an opportunity to endorse a series of reforms that would promote transparency and public participation while enhancing the quality of information received by agencies in the notice-and-comment process. Related Links: One suggestion is to hold […]

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Church-Affiliated Organization Benefit Plans Governed by ERISA

Mar 20, 2016 | Blog |

Stapleton v. Advocate Health Care Network, No. 15-1368 (March 17, 2016) N.D. Ill., E. Div. Affirmed The Court begins the decision, “The Employee Retirement Income Security Act (ERISA) protects employees from unexpected losses in their retirement plans by setting forth specific safe- guards for those employee plans. The Act, however, exempts church plans from those requirements. This case explores the question that has been brewing in the lower federal courts: whether a plan established by a church-affiliated organization, such as a hospital, is also exempt from ERISA’s reach. We conclude that it is not.”  The Third Circuit came to the […]

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ERISA Preemption in Case of Liberty Mutual Health Insurance Plan

Mar 20, 2016 | Blog |

The Supreme Court ruled that ERISA pre-empts Vermont’s statute as applied to ERISA plans in Gobeille v. Liberty Mutual Insurance Co., decided on March 1, 2016. Liberty Mutual maintains a self-insured employee health plan and some of those employees reside in Vermont. Vermont maintains a health-claims database (an “all-payor claims database” or APCD) that requires all health insurers and self-insured health plans operating in Vermont to report claims information. That information is then made available to insurers, employers, healthcare providers, and others to review issues such as utilization, cost, and quality with respect to healthcare in Vermont. Blue Cross Blue […]

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Congressional Research Service Social Security Primer

Feb 15, 2016 | Blog |

Congressional Research Service (“CRS”) has put out a “primer” on SSA: Social Security Primer Congressional Research Service Summary The Social Security program was established in the 1930s and has been modified by Congress many times over the years. Today, Social Security provides monthly cash benefits to retired or disabled workers and their family members, and to the family members of deceased workers. Among the beneficiary population, approximately 82% are retired or disabled workers, and 18% are the family members of retired, disabled, or deceased workers. In November 2015, nearly 60 million beneficiaries received a total of $74 billion in benefit payments […]

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Skilled Nursing Facilities Increase Therapy Minutes while Federal Fraud Enforcement Plays Catchup

Jan 27, 2016 | Blog |

The Medicare and Medicaid programs were established to ensure the health and medical needs of our nation’s aging and disabled populations. Unfortunately, a small number of doctors,hospitals,nursing homes,drug companies, and other health care providers have taken advantage of our tax dollars by making false claims to Medicare and Medicaid.Common fraudulent schemes include billing for unperformed services, upcoding,excessive service levels,questionable medical necessity,or referral kick backs. Over the past decade,the federal government, led primarily by the Department of Justice (DOJ) and Department of Health and Human Services (DHHS) has heightened its scrutiny of billing by skilled nursing facilities (SNFs).  Some of their […]

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Dismissal of Medline Industries False Claims Act Case Upheld

Jan 18, 2016 | Blog |

The Seventh Circuit upheld the dismissal of a suit filed in 2011 under the False Claims Act on January 4, 2016, finding the Relator was merely adding details to a prior kickback suit remarkably similar to his own.  Bogina v. Medline Industries, Inc., No. 15-1867 (7th Cir. 2016).  Thus, Relator Bogina failed the “original source” requirement as he was not “an individual who has direct and independent knowledge of the information on which the allegation [in his complaint] are based.”  31 USC § 3730(e)(4)(B).  Defendant Medline Industries, Inc. had previously settled a 2007 suit brought by Sean Mason, an employee […]

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Are Workers Compensation Benefits Affected By Other Benefits?

Jan 3, 2016 | Blog |

Whenever other benefits are involved in a WC claim, questions arise.   If a client gets Vet benefits, is there a reduction?  If Service Connected, no. If Non-Service Connected, yes. If client is getting UC & WC, will Social Security deny benefits?  Not necessarily. 820 ILS 405 Section 601(b)(1). If client has another WC claim pending in Ohio as well as Illinois, what then?  Confusing since Ohio is a reverse offset State. If client is going thru a divorce, does the spouse have an interest in the WC claim proceeds?  You betcha. Does CMS require that a Medicare set-aside arrangement […]

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Social Security Expedited Disability Claims

Jan 3, 2016 | Blog |

Social Security has several programs that will expedite a claim for disability benefits claims. One is to prevent homelessness. In fact, each Social Security local office has a designated staff member to handle such emergency situations.  Relevant POMS is below and available at: RS 02801.001 Critical Case Criteria and Exclusions A. Policy – critical case criteria SSA’s goal is to pay all benefits due on time. Processing critical cases has priority over all other workloads. Through routine processing, this goal is usually met. However, when a beneficiary is adversely affected because payment is not made timely, our goal is to […]

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