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Humana Medical Plan, Inc. v. Western Heritage Insurance Company

MOTION for Summary Judgment and Memorandum in Support

58 Cited authorities

  1. Chevron U.S.A. v. Natural Res. Def. Council

    467 U.S. 837 (1984)   Cited 16,028 times   504 Legal Analyses
    Holding that courts "must give effect to the unambiguously expressed intent of Congress"

  2. Thomas Jefferson Univ. v. Shalala

    512 U.S. 504 (1994)   Cited 1,276 times   5 Legal Analyses
    Holding that "the agency’s interpretation must be given controlling weight unless it is plainly erroneous or inconsistent with the regulation"

  3. Heckler v. Ringer

    466 U.S. 602 (1984)   Cited 1,753 times   2 Legal Analyses
    Holding that plaintiffs' claims were not wholly collateral to a statutory scheme of administrative and judicial review of Medicare payment decisions, where plaintiffs' constitutional and statutory challenge to an agency's procedure for reaching payment decisions was "at bottom" an attempt to reverse the agency's decision to deny payment

  4. Fidelity Federal Savings & Loan Ass'n v. De La Cuesta

    458 U.S. 141 (1982)   Cited 1,604 times   4 Legal Analyses
    Holding that a regulation authorizing federal savings-and-loan associations to include due-on-sale clauses in mortgage contracts conflicted with a state-court doctrine that such clauses were un-enforceable

  5. Shalala v. Illinois Council on Long Term Care, Inc.

    529 U.S. 1 (2000)   Cited 775 times   6 Legal Analyses
    Holding that a plaintiff cannot escape the requirements of 42 U.S.C. § 405(h) by phrasing what is essentially a claim for benefits as something other than a claim for monetary relief

  6. Sebelius v. Auburn Reg'l Med. Ctr.

    568 U.S. 145 (2013)   Cited 496 times   11 Legal Analyses
    Holding that "the presumption in favor of equitable tolling does not apply" to a nonjurisdictional agency appeal deadline given the statutory history and administrative context

  7. Glover v. Liggett Group, Inc.

    459 F.3d 1304 (11th Cir. 2006)   Cited 408 times
    Holding that a private plaintiff cannot sue a primary plan until that primary plan’s responsibility to pay "has been demonstrated" under paragraph(B)

  8. DO SUNG UHM v. HUMANA, INC

    620 F.3d 1134 (9th Cir. 2008)   Cited 145 times   3 Legal Analyses
    Holding that federal courts may not assert jurisdiction over claims under Section 405(g) where plaintiffs do not allege that they exhausted the administrative process

  9. Perry v. United Food and Com. Dist. Union

    64 F.3d 238 (6th Cir. 1995)   Cited 140 times
    Finding "very good reason for the plan provision excluding benefits which a beneficiary or plan participant is not legally obligated to pay," noting that payment of expenses that a participant is not legally obligated to pay would result in a windfall to the participant and a reduction of plan assets to pay expenses of other plan participants who incur legally enforceable expenses

  10. In re Avandia Mktg., Sales Practices & Prods. Liab. Litig.

    685 F.3d 353 (3d Cir. 2012)   Cited 75 times   3 Legal Analyses
    Holding that Section 1395y(b) provides a private right of action to MAOs

  11. Rule 12 - Defenses and Objections: When and How Presented; Motion for Judgment on the Pleadings; Consolidating Motions; Waiving Defenses; Pretrial Hearing

    Fed. R. Civ. P. 12   Cited 346,675 times   923 Legal Analyses
    Granting the court discretion to exclude matters outside the pleadings presented to the court in defense of a motion to dismiss

  12. Rule 56 - Summary Judgment

    Fed. R. Civ. P. 56   Cited 329,129 times   158 Legal Analyses
    Holding a party may move for summary judgment on any part of any claim or defense in the lawsuit

  13. Section 405 - Evidence, procedure, and certification for payments

    42 U.S.C. § 405   Cited 156,584 times   34 Legal Analyses
    Ruling out jurisdiction under 28 U.S.C. §§ 1331, 1346

  14. Rule 1 - Scope and Purpose

    Fed. R. Civ. P. 1   Cited 15,065 times   48 Legal Analyses
    Recognizing the federal rules of civil procedure should be employed to promote the "just, speedy, and inexpensive determination of every action and proceeding"

  15. Section 1395 - Prohibition against any Federal interference

    42 U.S.C. § 1395   Cited 2,265 times   29 Legal Analyses
    Addressing Medicare's reimbursement for diagnostic laboratory services for hospital outpatients

  16. Section 1395y - Exclusions from coverage and medicare as secondary payer

    42 U.S.C. § 1395y   Cited 1,299 times   66 Legal Analyses
    Granting the government subrogation rights

  17. Section 1395ff - Determinations; appeals

    42 U.S.C. § 1395ff   Cited 795 times   21 Legal Analyses
    Adopting the Social Security statute 42 U.S.C. § 405(g), which confers on federal courts the jurisdiction to hear Medicare claims after administrative review has been exhausted

  18. Section 1395ii - Application of certain provisions of subchapter II

    42 U.S.C. § 1395ii   Cited 545 times   2 Legal Analyses
    Adopting the Social Security statute 42 U.S.C. § 405(h), which strips federal courts of primary federal-question subject matter jurisdiction over Medicare claims

  19. Section 1395w-21 - Eligibility, election, and enrollment

    42 U.S.C. § 1395w-21   Cited 186 times   2 Legal Analyses
    Listing 42 U.S.C. §§ 1395w-22, 1395w-23, (g), (h), (m), 1395ww(d), (h)(D)

  20. Section 1395w-22 - Benefits and beneficiary protections

    42 U.S.C. § 1395w-22   Cited 184 times   13 Legal Analyses
    Stating that an MAO may charge a primary plan when a payment "is made secondary pursuant to section 1395y(b)"

  21. Section 411.24 - Recovery of conditional payments

    42 C.F.R. § 411.24   Cited 140 times   9 Legal Analyses
    Providing that a beneficiary who receives a primary payment "must reimburse Medicare within 60 days"

  22. Section 411.21 - Definitions

    42 C.F.R. § 411.21   Cited 59 times   1 Legal Analyses
    Defining "payer" separately from "plan"

  23. Section 422.108 - Medicare secondary payer (MSP) procedures

    42 C.F.R. § 422.108   Cited 58 times   1 Legal Analyses
    Elaborating upon an MAO's right to charge a primary plan and means of recovering a secondary payment

  24. Section 411.22 - Reimbursement obligations of primary payers and entities that received payment from primary payers

    42 C.F.R. § 411.22   Cited 46 times
    Stating that a primary payer's responsibility may be demonstrated by " A judgment; A payment conditioned upon the beneficiary's compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary payer or the primary payer's insured; or By other means, including but not limited to a settlement, award, or contractual obligation."

  25. Section 422.582 - [Effective until 6/3/2024] Request for a standard reconsideration

    42 C.F.R. § 422.582   Cited 6 times   1 Legal Analyses
    Providing an avenue for the provider to seek reconsideration of the organization determination