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District Court’s Verdict

December 2015 saw the judgment on a crucial case in the healthcare industry. The case was between a prominent insurance service and a healthcare provider, about the assignment of an out-of-network health insurance payment to the healthcare practitioner. The Third Circuit Court of Appeals, under whose jurisdiction both the insurance service and healthcare provider come, made the final judgment in favorer of the latter.

In this specific case, the insurance service Aetna was sued by the North Jersey Brain and Spine Center (NJBSC). The healthcare provider said that Aetna refused to pay for three surgeries. They were out of network for the patients. The patients were expecting the insurance reimbursement as per the Employment Retirement Income and Security Act (ERISA) health plans. However, they didn’t get any.

Before the surgeries were conducted, the healthcare provider had issued the assignments form to the patients and had made them sign it. Following that, the forms were forwarded to Aetna for confirmation, and they confirmed to cover the surgical expenses of the patients. Nevertheless, the insurance agency declined to pay the cost later. This made NJBSC sue Aetna.

Reports indicate that the patients authorized NJBSC to sue the insurance company on their behalf. The case was first filed at the District Court judge. However, the judgment was not in favor of NJBSC. So, it appealed to the Third Circuit Court of Appeals where it got a favorable judgment.

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In its petition, NJBSC pointed out that Aetna violated ERISA, which says that the healthcare provider has got the right to collect the expenses of treatment from the insurance provider. Meanwhile, the District Court judge, where the case first appeared, observed that the assignment forms were unclear. They did not have any provisions, giving NJBSC the right to sue the insurance provider in case the latter didn’t agree to pay the amount.

Nonetheless, when the case was moved to the Third Circuit Court of Appeals, it made a contrasting decision, making the judgment in favor of the healthcare provider. It observed that the authorization signs in the assignment forms were sufficient enough for NJBSC to sue the insurance provider and get the payments legally.

The court further noted that patients are increasingly becoming concerned about the payments getting processed from the insurance companies in contrary to Congress’s intent to safeguard plan participants. The latest judgment in favor of the healthcare provider, therefore, is indeed a positive gesture.

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