Justia Health Law Opinion Summaries

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A mental health patient lived in a forty-unit apartment building and repeatedly told his doctors and therapists he would kill an unnamed “neighbor.” He ultimately carried out his threat, killing an individual who lived in his building, a few doors away from his own apartment. In subsequent wrongful death litigation filed by the victim’s mother, the providers argued they had no duty to warn anyone about their patient’s threats because he never expressly identified a specific victim. The trial court rejected this argument and denied the providers’ motion for summary judgment, allowing the case to proceed to trial. On appeal, the Superior Court agreed, and finding no reversible error, the Pennsylvania Supreme Court affirmed. View "Maas v. Univ. of Pittsburgh Med. Ctr." on Justia Law

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Healthcare insurers filed suit challenging an emergency regulation promulgated in 2017 by New York's Superintendent of the Department of Financial Services that would have significantly reduced the amount of risk adjustment funding to which plaintiffs were entitled in 2017 under the Patient Protection and Affordable Care Act (ACA) and subsequent years using HHS's federal methodology. The Second Circuit held that New York's emergency regulation was preempted by the ACA and HHS's regulations. The court held that New York's regulation interferes with, indeed reverses, some of the central "criteria and methods" that HHS, acting within its statutory authority, established for implementing a risk adjustment program and methodology. Accordingly, the court reversed the portion of the district court's judgment that dismissed plaintiffs' preemption claim and remanded with instructions to grant summary judgment in plaintiffs' favor on that claim. The court also vacated the district court's dismissal of plaintiffs' takings and exaction claims, remanding for further proceedings. View "UnitedHealthcare of New York, Inc. v. Lacewell" on Justia Law

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J.L. and D.W. were covered by employer-sponsored Aetna insurance plans that provided out-of-network benefits only in cases of “Urgent Care or a Medical Emergency” (J.L.) or not at all (D.W.). J.L. needed bilateral breast reconstruction surgery and there were no in-network physicians available to perform the procedure. D.W. required facial reanimation surgery—a niche procedure performed by only a few U.S. surgeons. Both were referred for treatment to the Plastic Surgery Center, an out-of-network New Jersey medical practice. The Center negotiated with Aetna, which agreed to pay a “reasonable amount.” The Center billed $292,742 for J.L.’s services, Aetna paid only $95,534.04. Of the $420,750 the Center billed for D.W.’s services, Aetna paid only $40,230.32. The district court dismissed common law breach of contract, promissory estoppel, and unjust enrichment claims, holding that section 514(a) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1000, expressly preempted all claims. The Third Circuit reversed as the breach of contract and promissory estoppel claims, which do not require impermissible “reference to” ERISA plans. The claims, as pleaded, plausibly seek to enforce obligations independent of the plan and do not require interpretation or construction of ERISA plans. The claims plausibly arise out of a relationship that ERISA did not intend to govern. View "Plastic Surgery Center, P.A. v. Aetna Life Insurance Co" on Justia Law

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In these consolidated actions, a group of hospitals challenged HHS's rate reduction for off-campus provider-based departments (PBDs) falls outside of the agency's statutory authority. The district court agreed and set aside the regulation. Applying Chevron deference, the DC Circuit reversed and held that HHS's regulation rests on a reasonable interpretation of its statutory authority to adopt volume-control methods. In this case, Congress did not unambiguously forbid the agency from doing so and the agency reasonably read 42 U.S.C. 1395l(t)(2)(F) to allow a service specific, non-budget-neutral reimbursement cut in the circumstances the court considered here. View "American Hospital Assoc. v. Azar" on Justia Law

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The ACAP and others challenged the Departments' Short-Term Limited Duration Insurance (STLDI) Rule defining STLDI as coverage with an initial contract term of less than one year and a maximum duration of three years counting renewals. The Departments also expanded disclosure requirements. The DC Circuit affirmed the district court's grant of summary judgment to the Departments and agreed with the district court that the STLDI Rule was a reasonable interpretation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Patient Protection and Affordable Care Act (ACA), and that the change from the 2016 Rule to the current STLDI Rule was not arbitrary and capricious. View "Association for Community Affiliated Plans v. Department of the Treasury" on Justia Law

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The Supreme Judicial Court affirmed the order of the district court committing M. to involuntary hospitalization for up to 120 days, holding that the evidence was sufficient to support the court's decision to order M.'s involuntary hospitalization. The district court authorized M.'s hospitalization for up to 120 days, and the superior court affirmed. On appeal, M. argued that she was denied due process and a fair appeal because there was no verbatim transcript of her commitment hearing and that the record contained insufficient evidence to support the court's findings. The Supreme Judicial Court affirmed, holding (1) the opportunities afforded to M. to supplement the incomplete transcript were sufficient to satisfy due process; and (2) there was sufficient evidence to support the district court's decision. View "In re Involuntary Commitment of M." on Justia Law

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The Fifth Circuit reversed the Commission's decision affirming the application of OSHA's commercial diving safety regulations to the dives its staff members perform to feed animals housed at the Aquarium and to clean the facility's tanks. A majority of the Commission panel affirmed the ALJ's determination that feeding and cleaning dives did not fall within the "scientific diving" exemption to the commercial standard. The court held that the ALJ did not err in crediting the compliance officer's testimony about the Commercial Diving Operations (CDO) standard as lay opinion testimony; even if the compliance officer testified to some matters that fell outside the realm of lay opinion testimony, the admission of the testimony was harmless; and the Aquarium's witnesses were properly treated as lay witnesses. Under a plain reading of the entire definition of "scientific diving," as well as the regulation guidelines and regulatory history, the court held that the activities performed during the feeding and cleaning dives fall within the plain text of the exemption. In this case, the Aquarium has shown that feeding and cleaning dives are a necessary component of its scientific research. View "Houston Aquarium, Inc. v. Occupational Safety and Health Review Commission" on Justia Law

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The Eleventh Circuit affirmed the district court's dismissal based on lack of standing of this action for damages under the Medicare Secondary Payer Act and remanded with instructions for the district court to dismiss the complaint with prejudice. The court held that the Addendum (but not the Nunc Pro Tunc Assignment) is impermissible parol evidence; although the Nunc Pro Tunc Assignment could create standing on the basis of retroactive assignment of claims, plaintiffs did not receive any rights under it; and the court declined to consider whether the Recovery Agreement by itself equitably assigned plaintiffs HFHP's rights under the Act because plaintiffs did not assert this argument before the district court. View "MSP Recovery Claims, Series LLC v. QBE Holdings, Inc." on Justia Law

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Appellants-patients Nathaniel Valencia and Emily Williams were self-pay patients who received emergency medical services at Saint Alphonsus Medical Center—Nampa, Inc. (“Saint Alphonsus”) in 2015. During their respective visits, Patients agreed to pay for “all charges incurred” for services rendered to them. Patients were billed in accordance with Saint Alphonsus’ “chargemaster” rates. Patients sought declaratory relief requesting the district court to rule Saint Alphonsus was only entitled to bill and seek collection of the reasonable value of the treatment provided to self-pay patients. Saint Alphonsus moved the district court to dismiss the complaint pursuant to Idaho Rule of Civil Procedure 12(b)(6). The district court treated the motion to dismiss as a motion for summary judgment pursuant to I.R.C.P. 12(d). Ultimately, the district court granted summary judgment for Saint Alphonsus, and Patients timely appealed. Finding no reversible error, the Idaho Supreme Court affirmed. View "Williams v. St. Alphonsus Medical Center" on Justia Law

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Plaintiffs, who have hearing loss severe enough to qualify them as disabled, filed suit claiming that Kaiser's health insurance plan's categorical exclusion of most hearing loss treatment discriminates against hearing disabled people in violation of Section 1557 of the Patient Protection and Affordable Care Act (ACA). The district court ruled that Kaiser's plans do not exclude benefits based on disability because the plans treat individuals with hearing loss alike, regardless of whether their hearing loss is disabling. The Ninth Circuit agreed with the district court that plaintiffs have failed to state a plausible discrimination claim. The panel explained that the ACA specifically prohibits discrimination in plan benefit design, and a categorical exclusion of treatment for hearing loss would raise an inference of discrimination against hearing disabled people notwithstanding that it would also adversely affect individuals with non-disabling hearing loss. However, the exclusion in this case is not categorical. The panel stated that, while Kaiser's coverage of cochlear implants is inadequate to serve plaintiffs' health needs, it may adequately serve the needs of hearing disabled people as a group. Therefore, the panel affirmed the district court's dismissal of the second amended complaint. The panel reversed the district court's dismissal without leave to amend and remanded. View "Schmitt v. Kaiser Foundation Health Plan of Washington" on Justia Law