TITLE

FOCUS ON DISCLOSURE AND MISREPRESENTATION

AUTHOR(S)
Hesse, Katherine A.; Ehrens, Doris R. MacKenzie
PUB. DATE
June 1998
SOURCE
Benefits Quarterly;1998 Second Quarter, Vol. 14 Issue 2, p86
SOURCE TYPE
Academic Journal
DOC. TYPE
Article
ABSTRACT
This section provides an update on several court rulings concerning various employee benefits-related cases in the U.S. as of June 1998. In Jane Doe v. Travelers Insurance Co., decisions of out-of-court decision makers with discretionary authority are reviewed using an arbitrary and capricious standard that requires more strict scrutiny when the decision maker acts under a conflict of interest. In Shea V. Esensten, a former participant's widow has standing to bring an action for violation of fiduciary duty that caused the former participant to lose his participant status. A plan must disclose financial incentives that discourage a treating doctor from providing essential health care referrals for conditions covered under the plan benefit structure. In Forsyth v. Humana Inc., employees can recover damages from an insurer pursuant to an Employee Retirement Income Security Act (ERISA) breach-of-contract claim in the amounts they were forced to pay over and above their contractual copayment percentage where a hospital gave the insurer a discount so that it paid less than the percentage it was required to pay under the plan. Employees do not have standing to make an ERISA claim for breach of fiduciary duty when they have another adequate remedy.
ACCESSION #
600408

 

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