Case No. 10-55696;
D.C. No. 2:07-cv-05512-GAF-CW, unpublished,
filed January 12, 2012, United States Court of Appeals for the Ninth Circuit.
Samano v. Kaiser Foundation Health Plan PDF file
Consequences of Court Decision:
- The most popular “Prompt Pay Discount” practices may not be ERISA compliant.
- Difference between PPO discount and ERISA OON Discount.
- Increasing payer health care fraud allegations against all OON discount practices in federal and state court.
- Feds: About 77% insured Americans in employer sponsored health plans have out-of-network coverage, and may be in need of ERISA OON discount: http://stats.bls.gov/ncs/ebs/detailedprovisions/2010/ebbl0047.pdf (BLS, NBS 2010, page 11 of 167)
- ERISA compliant OON discount, for preventing and defending against the fraud allegations and ERISA challenges.
“1. The district court properly awarded summary judgment in favor of Kaiser on Samano’s claims for ERISA benefits. Once Providence applies the discounted rate to a patient’s bill, that sum is the maximum amount the patient owes Providence. Thus, the district court correctly concluded that Samano has received all the benefits owed under his ERISA plan and is not entitled to reimbursement for the original, nonbilled, amount of benefits that Kaiser might have owed Providence had it originally recognized that Samano was entitled to coverage. Under the circumstances, such an award of benefits to Samano would be a windfall, not permitted under ERISA, 29 U.S.C. § 1132(a)(1)(B). Under ERISA, a beneficiary may not recover “extracontractual, compensatory [or] punitive damages.” Bast v. Prudential Ins. Co. of Am., 150 F.3d 1003, 1009 (9th Cir. 1998). Moreover, the district court properly ordered that if Providence makes any further claim arising from the emergency medical services rendered in August and September, 2006, Kaiser will be required to reimburse Samano for such a claim.”