ERISA MEDICAL PAYMENT REIMBURSEMENT

[latha]

My son-in-law was seriously and permanently injured in a car/truck collision in 1998. My daughter's group health carrier (governed by ERISA) paid medical bills totalling $17,100. The liability claim has now been settled and the group carrier is seeking reimbursement for their payments. According to my son-in-law's attorney, Georgia law would limit or not allow the carrier to enforce their reimbursement claim in this case; however, ERISA gives the carrier the right to get back everything they have paid out even if the injured party has not been fully compensated for his injuries.

This seems very unfair to me and I would like to know if anyone out there can provide more information about situations involving a conflict in State and Federal Law.

 

[lawrat]

I am a law school graduate currently awaiting Bar results. I offer information to you, not to be construed as forming an attorney-client relationship.

You health insurance is seeking reimbursement from you (based on your judgment)? Hmm, it sounds like going against the whole point of insurance in the first place.

I know that in terms of what evidence a person can bring into a court of law, the fact of having insurance or insurance paying for medical bills doesn't negate the liability of the wrongdoer. I also know that double recovery is not allowed, but I think that is in the case of getting the full amount of damages from each defendant (if more than one defendant).

Here, if there is already a money judgment in your favor, I don't see why the health carrier is asking it from you. They are the in the business of paying for medical costs like these when they have an insured on their policy.

I don't know why ERISA would allow this and it doesn't seem fair. I am not a health insurance or recovery expert, but have you tried reading the INSURANCE section at freeadvice.com?

Have you thought about getting (or least talking to) another atty? someone familiar with ERISA specifically? try attorneypages.com (some offer free consultations). at least they may be able to tell you if you are in the right about the reimbursement issue or not.

hope this helps.

 

[latha]

Thanks for your response to my ERISA reimbursement question.

Unfortunately, I have read a 1993 case involving an interpretation of the Federal Law and it is totally at odds with Georgia Law which will not allow any reimbursement of a health carrier if the injured party is not made whole. Further, Georgia Law allows for a reduction of the amount of the reimbursement being claimed by the percentage of the recovery equal to attorney's fee and costs incurred to collect the udgment or settlement.

You are right, it doesn't seem fair, but I think the insurance companies must have enough members of Congress in their hip pockets to allow this to continue. As I said, the latest case I have found on the subject is 1993 and I was hoping somebody out there might know of a more recent case that would be useful to my son-in-law's situation.

Thanks again for your response and good luck in you chosen field.

 

[lars coltrane]

The bad news: ERISA, being Federal law, supercedes the more favorable state law. It is like this in CA.

The best you can do is to try to negotiate some settlement.

 

[latha]

LARS:

Thanks for your reply. I understand that Federal Law rules; however, that doesn't keep it from being unfair--in my opinion that is.

Nell

 

[lars coltrane]

I completely agree. I have yet to hear about an insurance company that gets reimbursed and then turns around and says to its subscriber - here is a refund for last years premium; you deserve the money back because we were able to get reimbursed. In my dreams.

 

[latha]

Maybe someone with a lot of time, could start a grass roots movement to let Congress know some of us common folk think ERISA stinks to high heaven. I believe the common (little) people are the ones who were supposed to be protected by, and benefit from, this piece of legislation (or whatever it is). Hope this is not out of line for this site.

 

[jakjd]

This whole process is called"subrogation". As an attorney working for a subrogation company a few years back, I am very familiar with this concept. We worked with self-funded, or funded employer group plans quite often regarding the recovery of medical expenses for the insurer pursuant to ERISA. Keep in mind that their ability to recover is only as good as the subrogation language in your contract for health insurance. That language will be STRICTLY enforced. Look for any ambiguities or references that will move this back to the states jurisdiction. Often times there are many mistakes and ambiguities. I've seen them all the time. Hope this helps.

 

[latha]

Thanks for your message. Can you give me any examples of errors or ambiguities I should look for in this contract?