The Conflict of Interest Inherit in Administrative Review I. Introduction The Employee Retirement Income Security Act, better known as ERISA, has been a major issue in healthcare litigation since its inception in 1974. ERISA governs any claim centering on health insurance, disability insurance, or any other employer provided benefits. ERISA affects many aspects of the American legal system, from inter-state commerce to bankruptcy, and particularly insurance and healthcare law. ERISA contains clauses for both the procedure and substance of the law and is often preemptive over state law. There is a great deal of misunderstanding and confusion surrounding the application and coverage of ERISA, which has made litigation even more complex and hazardous. Understanding the basic procedure, coverage and intricacies of ERISA's implications and formalities is essential for any attorney practicing insurance or healthcare law. This past year I was personally involved in an ERISA litigation suit. This suit involved a woman working for The Mutual of Omaha Companies. She was denied a breast reduction surgery by her employer-run health plan. This surgery had been recommended by her physician and deemed "medically necessary." However, her health insurance plan exempted all forms of breast surgery, not involving cancer, from coverage regardless of their necessity. Our client, the insurance participant ("client") then came to our office to see what assistance we could provide in helping her obtain coverage for this surgery. At this point, our office thought that the chances for recovery of any benefits were very slim due to the fact that the health insurance policy specifically excluded breast reduction surgery from coverage... ... middle of paper ... ...d reading case law discussing ERISA, I do not think that the true intention of ERISA is fulfilled when the law is construed to protect employers and administrators. Some argue that plan beneficiaries have the right to choose a plan and if they buy into a benefit plan which gives the administrator the power to interpret the plan and it's terms, that is the beneficiary's choice. I completely disagree. I contend that a vast majority of employee/beneficiaries never read the provisions of the plan, and would not understand the plan's implications even if they had read the provisions. ERISA was intended to secure and protect an employee's rights and benefits for the employee's future use. Under the current standard of review, as strictly applied from the Brunch decision, the court system is not protecting the interest that ERISA was designed to safeguard.
Pozgar, G.D. (2012). Legal Aspects of Health Care Administration. United States of America: Jones and Bartlett Learning, LLC.
Steiner, John E. (2013). Problems in health care law: challenges for the 21st century (10th ed.). Burlington, MA: Jones & Bartlett Learning.
COBRA was passed in 1986 and provides guidelines for continuous health coverage in case of sudden loss of a job or even death among other situations that cannot be avoided. Employees as well as employers have to participate in the program to make it effective. The employees are guided by the “Employee Benefits Security Administration” and the “Employee Retirement Income Security Act” to fill out forms of compliance. The law was designed to find temporary solutions for continued medical insurance so that the unemployed can still enjoy and access healthcare facilities despite the financial misfortunes that may render them unable to support themselves as well as their families as they find a permanent solution (Magill, 2009).
"U.S. Judge Rules Health Care Reform Act Unconstitutional | Business Insurance." Business Insurance News, Analysis & Articles. Web. 20 Mar. 2011. .
GMFC Company has many divisions and more than 50,000 employees. Initially, the company health care proposal had a lifetime advantage of $2 million per enclosed employee or dependent. However, the company only extends coverage to dependents enrolled to a degree program. Subsequently, the coverage benefits individuals up to the age of 22 years. However, PPACA required GMFC to alter its coverage to house new advantages and age limit demands. According to GMFC, changing the current plan coverage to accommodate age limit requirements and new benefit will lead to additional cost. Therefore, the company is considering abandoning health care coverage and subscribing to federal penalties. If GMFC adopts such an action, employees will purchase insurance
Health Insurance Portability and Accountability Act or HIPAA is a statute endorsed by the U.S. Congress in 1996. It offers protections for many American workers which improves portability and continuity of health insurance coverage. The seven titles of the final law are Title I - Health care Access , Portability, Title II - Preventing Health Care Fraud and Abuse; administrative simplification; Medical Liability Reform; Title III – Tax-related Health Provisions; Title IV – Application and Enforcement of Group Health Plan Requirements; Title V – Revenue Offsets; Title XI – General Provisions, Peer Review, Administrative Simplification; Title XXVII – Assuring Portability, Availability and Renewability of Health Insurance Coverage. (Krager & Krager, 2008)
The Health Insurance Portability and Accountability Act, most commonly known by its initials HIPAA, was enacted by Congress then signed by President Bill Clinton on August 21, 1996. This act was put into place in order to regulate the privacy of patient health information, and as an effort to lower the cost of health care, shape the many pieces of our complicated healthcare system. This act also protects individuals from losing their health insurance if they lose their employment or choose to switch employers. . Before HIPAA there was no standard or consistency for the enforcement of the privacy for patients and the rules and regulations varied by state and organizations. HIPAA virtually affects everybody within the healthcare field including but not limited to patients, providers, payers and intermediaries. Although there are many parts of the HIPAA act, for the purposes of this paper we are going to focus on the two main sections and the four objectives of HIPAA, a which are to improve the portability (the capability of transferring from one employee to another) of health insurance, combat fraud, abuse, and waste in health insurance, to promote the expanded use of medical savings accounts, and to simplify the administration of health insurance.
Jacobson, P. (1999, July/August). Legal challenges to managed care cost containment programs: an intital assessment. Courts & Managed Care, 69-85.
"Surgery to Reduce the Risk of Breast Cancer Fact Sheet - National Cancer Institute." National Cancer Institute. National Institutes of Health. Web. 06 Jan. 2014. .
... ensure all eligible employees are covered under the Family Medical Leave Act and their unalienable rights are not violated. The Act ensures that an employee will not be unduly terminated due to a medical condition of their own or close family and their job will be secure for the term of leave. The long wait for the Family Medical Leave Act has not been a waste. Since the Act's inception, millions of people have benefited from the twelve weeks approved by the Government. The number of employers and employees the Family Medical Leave Act affected went above and beyond the projected numbers, thus showing the increasing need for protection due to a "serious health condition" of an employee or employee's family. The numbers are projected to only increase in the next five years because of the number of workers that will need to take leave under the Act at some time.
Governing bodies for the prevention, treatment, and management of illnesses in America are now in a commotion because of the cost of care and patient access and the need for a more efficient system. There are approximately 50 or more million people currently in The United States that are without insurance today. In March of 2010 a country wide health care charge called The Patient Protection and Affordable Care Act was passed, that seemed to offer solutions to some of the major issues facing our health care system. June of 2012, this new health care law or tax was challenged in the U. S. Supreme Court on the Constitutionality of the bill with proponents wanted the Act repealed. A few weeks later the Supreme Court gave its answer, which was the law or tax is Constitutional and upheld it as tax. One of the biggest issues to this Act was the part where all Americans have to be insured by someone or be penalized, but the final analysis of this...
...o have had breast implants often cannot get health insurance because they have an increased risk of illness. If a woman is able to obtain health insurance she may have to pay a higher premium because of her past plastic surgery history.
The push for Congress to pass legislation protecting the rights of employees and their retirement was inevitable. Retirement plans are extremely important for all working individuals. Having funds to keep or exceed ones current standard of living and to enjoy one’s life beyond expectations after retire...
Offering employee benefits is one way a company must competes in today’s marketplace to retain old employees and attracts new ones. These benefit packages may range from offering basic health insurance to additional discretionary and perk benefits such as vacation and retirement packages. Benefit packages are often a large portion of employee costs and Federal mandates require an employer to carry and offer certain benefits even if they offer nothing else. Federally required employee benefits make up approximately a quarter of the costs associated with employer offered benefit packages. Some of these mandated benefits include Social Security, Worker’s Compensation Insurance, and the Family Medical Leave Act.
Although primary objective for managers is to maximise shareholders’ wealth, but many firms are started to focus on other stakeholders’ interests in recent years. Company can prevent transfer the damage of stakeholders’ wealth to shareholders when focus on stakeholders’ interests. In other words, “social responsibility” for the companies is to maintenance stakeholders’ relations in order to provide long-term interests to shareholders. By this way, conflict, turnover and litigation of stakeholders can be minimise. Obviously, company can achieve their primary objective by cooperation with stakeholders instead of conflict with stakeholders (Smart, Megginson, Gitman, 2002).