Jacqueline Fisher v. Aetna Life Insurance Company, No. 20-3148 (2d Cir. 2022)
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Plaintiff argued that the insurance contract between the parties was governed by a document provided on January 9, 2014, instead of February 19, 2014; that she is entitled to a judgment based on the insurance company’s miscalculation of her copay; and that even if the February 19 document controls, the Patient Protection and Affordable Care Act, 42 U.S.C. Section 18022(c)(1) (“ACA”), mandates that the insurance company must apply the individual out-of-pocket limit rather than the family out-of-pocket limit; and that the generic-brand cost differential Plaintiff paid for her name-brand medication should count toward her out-of-pocket limit. Plaintiff filed a breach of contract claim under ERISA, and the district court granted Defendant judgment on the breach of contract claims under ERISA.
The Second Circuit affirmed the district court’s judgments. The court held that the February document governed the relationship between the parties because Plaintiff was on notice as to its terms. Further, Plaintiff is not entitled to a money judgment for her copay because Defendant agreed to pay Plaintiff the copay differential.
The court also found that the ACA does not provide that the annual limitation on cost-sharing applies to all individuals regardless of whether the individual is covered under an individual “self-only” plan or is covered by a plan that is other than self-only for plans effective before 2016. Finally, the court held that the ACA nor the February document required Defendant to apply the brand-generic cost differential costs to Plaintiff’s out-of-pocket limit.
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