The Conflict of Interest Inherit in Administrative Review Essay example

4586 Words 19 Pages
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
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Thereafter, our case quickly became a question of whether the healthcare administrator was precluded from denying coverage for breast reduction surgery, when it had granted coverage for the same on three previous occasions. The U.S. District Court held that the plan administrator was precluded from denying the claim, when they had granted coverage in the exact same medical circumstances on three previous occasions. This case is currently on appeal with the Eighth Circuit.
The issue that I found most compelling while researching ERISA procedure was the administrative appeal process, and the standard of review to which the U.S. District Court must adhere. The U.S. District Court was required to review a case on appeal, after the exhaustion of administrative remedies, only for an abuse of discretion, so long as discretion had been granted to a plan administrator within the plan. In our suit, the health insurance policy did contain a clause that gave the administrator discretion to interpret and review, therefore our burden of proof was to convince the U.S. District Court judge that the administrator had abused his discretion and denied coverage beyond what the administer believed were the policy…