Justia Health Law Opinion Summaries

The Plan is a nonprofit health care service plan subject to Health & Safety Code 1340, including the Parity Act, under which: “Every health care service plan contract . . . that provides hospital, medical, or surgical coverage shall provide coverage for the diagnosis and medically necessary treatment of severe mental illness of a person of any age, and of serious emotional disturbances of a child . . . under the same terms and conditions applied to other medical conditions.”Plaintiffs alleged that the Plan violates the Parity Act by “deterring members from obtaining one-on-one mental health therapy without making individualized determinations … encouraging ‘group’ therapy, without making individualized determinations" where similar practices are not followed in the treatment of physical health conditions. An Unruh Civil Rights Act claim alleged that the Plan intentionally discriminated against persons with mental disabilities or conditions. The court granted the Plan summary judgment.The court of appeal affirmed the rejection of one plaintiff’s individual claims; the Plan is not liable for the acts of its subsidiary by whom the plaintiff’s coverage was issued. The court otherwise reversed. On an Unfair Competition Law claim, the court failed to consider how the Plan’s conduct undermines its contractual promises of covered treatment in violation of the Parity Act. On the Unruh claim, triable issues of fact exist as to whether the plaintiffs were denied medically necessary treatment as a result of intentional discrimination. View "Futterman v. Kaiser Foundation Health Plan, Inc." on Justia Law

Middle schooler A.K. struggled with suicidal ideation for many years and attempted suicide numerous times, resulting in frequent emergency room visits and in-patient hospitalizations. A.K.’s physicians strongly recommended she enroll in a residential treatment facility to build the skills necessary to stabilize. Despite these recommendations and extensive evidence in the medical record, United Behavioral Health (“United”) denied coverage for A.K.’s stay at a residential treatment facility beyond an initial three month period. Her parents appealed United’s denial numerous times, requesting further clarification, and providing extensive medical evidence, yet United only replied with conclusory statements that did not address the evidence provided. As a result, A.K.’s parents brought this lawsuit contending United violated its fiduciary duties by failing to provide a “full and fair review” of their claim for medical benefits. Both sides moved for summary judgment, and the district court ruled against United. The issue this case presented for the Tenth Circuit's review was whether United arbitrarily and capriciously denied A.K. medical benefits and whether the district court abused its discretion in awarding A.K. benefits rather than remanding to United for further review. The Court ultimately concluded United did act arbitrarily and capriciously in not adequately engaging with the opinions of A.K.’s physicians and in not providing its reasoning for denials to A.K.’s parents. The Court also concluded the district court did not abuse its discretion by awarding A.K. benefits outright. View "D.K., et al. v. United Behavioral Health, et al." on Justia Law

Alabama Somerby, LLC, d/b/a Brookdale University Park IL/AL/MC; Brookdale Senior Living, Inc.; and Undrea Wright (collectively, Brookdale) appealed a circuit court's order denying their motion to compel arbitration of the claims asserted against them by plaintiff, L.D., as the next friend of her mother, E.D. Brookdale operated an assisted-living facility for seniors ("the nursing home") in Jefferson County, Alabama; Wright was the administrator of the nursing home. In March 2022, L.D. filed on E.D.'s behalf, a complaint against Brookdale and Wright and others, asserting various tort claims and seeking related damages premised on allegations that, following her admission to the nursing home, E.D. had been subjected to multiple sexual assaults both by other residents and by an employee of Brookdale. The Brookdale defendants jointly moved to compel arbitration of L.D.'s claims against them or, alternatively, to dismiss the action without prejudice to allow those claims to proceed via arbitration. Following a hearing, the trial court, denied the motion seeking to dismiss the action or to compel arbitration. The Brookdale defendants timely appealed, asserting that the trial court had erred by failing to order arbitration. The Alabama Supreme Court concluded the Brookdale defendants established that an agreement providing for arbitration existed and that the agreement affected interstate commerce. The trial court erred in denying the Brookdale defendants' request to compel arbitration. The Supreme Court reversed the trial court's order and remanded the case for further proceedings. View "Alabama Somerby, LLC, et al. v. L.D." on Justia Law

The Supreme Court dismissed this direct appeal brought by the Iowa Department of Human Services (HDS) from a district court ruling requiring Iowa's Medicaid program to pay for sex reassignment surgery for two transgender adults and affirmed the denial of fees on cross-appeal, holding that the appeal was moot.Petitioners, adult transgender Iowans who were denied preauthorization for sex reassignment surgeries through the Medicaid program, appealed their managed care organization's denial of coverage to DHS. DHS affirmed the denials. The district court reversed, concluding that Iowa Code 216.7(3), an amendment to the Iowa Civil Rights Act (ICRA) violated the guarantee of equal protection under the Iowa Constitution. DHS appealed, but, thereafter, agreed to pay for Petitioners' surgeries. The Supreme Court dismissed the direct appeal as moot and affirmed the district court's order denying any fee award, holding that the court erred in denying Petitioners' request for attorney fees. View "Vasquez v. Iowa Dep't of Human Services" on Justia Law

In an interlocutory appeal, multiple hotel operators challenged a superior court’s orders in a suit against defendants, multiple insurance underwriters, all relating to the denial of coverage during the COVID-19 world health pandemic. Plaintiffs owned and operated twenty-three hotels: four in New Hampshire, eighteen in Massachusetts, and one in New Jersey. Plaintiffs purchased $600 million of insurance coverage from defendants for the policy period from November 1, 2019 to November 1, 2020. With the exception of certain addenda, the relevant language of the policies was identical, stating in part that it “insures against risks of direct physical loss of or damage to property described herein . . . except as hereinafter excluded.” For periods of time, pursuant to governors’ orders, hotels in each of the three states were permitted to provide lodging only to vulnerable populations and to essential workers. These essential workers included healthcare workers, the COVID-19 essential workforce, and other workers responding to the COVID-19 public health emergency. Beginning in June 2020, plaintiffs’ hotels were permitted to reopen with a number of restrictions on their business operations. Plaintiffs, through their insurance broker, provided notice to defendants they were submitting claims in connection with losses stemming from COVID-19. Plaintiffs sued when these claims denied, arguing that the potential presence of the virus triggered business loss provisions in their respective policies. To this, the New Hampshire Supreme Court disagreed, finding that “[w]hile the presence of the virus might affect how people interact with one another, and interact with the property, it does not render the property useless or uninhabitable, nor distinctly and demonstrably altered.” View "Schleicher & Stebbins Hotels, LLC, et al. v. Starr Surplus Lines Insurance Co., et al." on Justia Law

Victor Chin, M.D., and Sportsmed Orthopedic Specialists, P.C. (collectively "the Sportsmed defendants"), were defendants in an action brought by their patient, Malik Woodard. Woodard alleged that, against his wishes, Dr. Chin obtained records of Woodard's prior psychological treatment. The Sportsmed defendants sought mandamus relief from: (1) the circuit court's order denying their motion to change venue based on the Alabama Medical Liability Act and the Alabama Medical Liability Act of 1987 (collectively "AMLA"); and (2) the court's order prohibiting them from using the psychological records (and certain related documents) in the case and requiring them to return or destroy those records and documents ("the protective order"). As to the venue order, the Alabama Supreme Court denied the petition because the Sportsmed defendants did not argue that the complaint did not support an inference that Dr. Chin had no medical reason for obtaining the psychological records. As to the protective order, the Supreme Court denied the petition because the Sportsmed defendants did not demonstrate that the order was subject to mandamus review. View "Ex parte Victor Chin, M.D., and Sportsmed Orthopedic Specialists, P.C." on Justia Law

The 2005 Medicare amendment, launching prescription drug coverage, raised concerns that patient assistance plans could violate the Anti-Kickback Statute, 42 U.S.C. 1320a-7b, and the False Claims Act, 31 U.S.C. 3729, by effectively rewarding doctors and patients for choosing particular drugs. Astellas subsequently launched Xtandi, used to treat metastatic prostate cancer. Priced at $7,800 per month, Xtandi prescriptions were covered by Medicare up to about $6,000 per month. Astellas made contributions to two patient assistance plans. An Astellas marketing executive encouraged both plans to create special funds to provide co-pay assistance for only androgen receptor inhibitors like Xtandi and a few other medications. Astellas donated to the new funds but stopped after contributing about $27 million. Astellas continued contributing to broader prostate cancer funds.The Department of Justice began investigating; the Astellas marketing executive acknowledged that he had “hoped” and “expected” that the contributions would produce financial benefits for Astellas but that Astellas had made no efforts to calculate “a return on investment.” Astellas settled with the government for $100 million--$50 million for “restitution” to the government. Astellas sought indemnification from liability insurers, including Federal, which denied coverage.The Seventh Circuit affirmed summary judgment for Astellas. Under Illinois law, a party may not obtain liability insurance for genuine restitution it owes the victim of its intentional wrongdoing, but a party may obtain insurance for compensatory damages. In cases of ambiguity, Illinois favors settlements and freedom of contract. Federal wrote its insurance policy to try to extend coverage to the limit of what Illinois law would allow. Federal did not carry its burden of showing that the portion of the settlement payment for which Astellas seeks coverage is uninsurable restitution. View "Astellas US Holding, Inc. v. Federal Insurance Co." on Justia Law

The Supreme Court affirmed the decision of the court of appeals reversing the circuit court's issuance of an injunction compelling Aurora Health Care, Inc. to administer Ivermectin to Petitioner's uncle (Patient), holding that the circuit court abused its discretion in issuing the injunction without analyzing Petitioner's reasonable probability of success on the merits.Patient was in Aurora's care when he tested positive for COVID-19. Petitioner, who held health care power of attorney for Patient, received a prescription for Ivermectin from a retired OB/GYN, but Aurora declined to effect the prescription. Thereafter, Petitioner bright a complaint seeking declaratory and injunctive relief. The circuit court issued an order compelling Aurora immediately to enforce the prescription and administer Ivermectin to Patient. The court of appeals reversed. The Supreme Court affirmed, holding that the circuit court erroneously exercised its discretion by issuing the temporary injunction without referencing any basis demonstrating that Petitioner had a reasonable probability of success on the merits of "some type of legal claim." View "Gahl v. Aurora Health Care, Inc." on Justia Law

Appellants Crestwood Behavior Health, Inc. (Crestwood), West Anaheim Extended Care and Extended Care Hospital of Westminster (West Anaheim), and Royale Health Care Center dba South Coast Post Acute (South Coast) (together, appellants) operated skilled nursing facilities serving beneficiaries of the California Medical Assistance Program (Medi-Cal). Respondent Department of Health Care Services (the Department) administered Medi-Cal. As relevant here, the Department also administered the “Skilled Nursing Facility Quality and Accountability Supplemental Payment System” (QASP), which authorized supplemental payments, over and above Medi-Cal reimbursement rates, to skilled nursing facilities meeting certain performance standards. Consolidated appeals challenged the Department’s method for calculating QASP payments. Appellants argued they did not receive all the QASP payments to which they were entitled and blame the alleged underpayment to the Department’s practice of excluding certain Medi-Cal days—known as “special treatment program days” or “STP days”—from its calculations. They sought writs of mandate directing the Department to include STP days in the calculation of QASP payments. The Court of Appeal concurred with the trial court that appellants failed to identify an appropriate basis for writ relief. Appellants sued under Welf. & Inst. Code Section 14170 (a)(1), which did not impose a mandatory or ministerial duty on the Department that could support the issuance of a writ of mandate. And the Court found appellants did not show any abuse of discretion by the Department. Accordingly, the trial court judgment was affirmed. View "Crestwood Behavioral Health, Inc. v. Baass" on Justia Law

Bridges and Cunningham filed a putative class action, alleging that Blackstone (the owner of Ancestry.com) violated Section 30 of Illinois’s 1998 Genetic Information Privacy Act, which provides that no person or company “may disclose or be compelled to disclose the identity of any person upon whom a genetic test is performed or the results of a genetic test in a manner that permits identification of the subject of the test,” 410 ILCS 513/30(a). Both plaintiffs had purchased DNA testing products from Ancestry and submitted saliva samples for genetic sequencing years earlier. Blackstone subsequently purchased Ancestry in a “control acquisition”— an all-stock transaction. Because Ancestry had allegedly paired the plaintiffs’ genetic tests with personally identifiable information—including names, emails, and home addresses—Bridges and Cunningham maintained that Blackstone, as part of acquiring Ancestry, had compelled the disclosure of their genetic identities in violation of Section 30.The Seventh Circuit affirmed the dismissal of the suit for failure to state a claim. The complaint focusing exclusively on Blackstone’s acquisition of Ancestry did not adequately allege any compulsory disclosure. View "Bridges v. Blackstone, Inc." on Justia Law