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Expert Analysis

Courts Continue To Clarify ERISA Pleading Standards

By Larisa Vaysman (March 29, 2018, 10:49 AM EDT) -- When an insured employee is treated at an in-network provider, her insurer will typically reimburse the provider directly at the agreed-upon contract rate for the treatment. With out-of-network providers, however, things are not so clear-cut. The insurer has no direct contractual relationship with the provider, but the provider wants to be reimbursed directly. There is no agreed-upon rate, but the provider and insurer both have an opinion as to what constitutes a reasonable reimbursement. In numerous cases, these ambiguities have spawned litigation....

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