Adam V. Russo | November 21, 2008
Farie v. Jeld-Wen, Inc., 2008 U.S. Dist. LEXIS 88893 (N.D. Ohio) (Oct. 31, 2008).
The plan participant was injured in a car accident and refused to reimburse the health plan for medical claims paid.
The Court stated that “the make-whole rule provides that an insurer cannot enforce its subrogation rights unless and until the insured has been made whole by any recovery, including any payments from the insurer”. (more…)
Category: 6th, Made Whole Rule |
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Adam V. Russo | November 18, 2008
The Latest Article from The Health Care Blog by Brian Klepper
These are, as the Chinese curse reputedly called them, interesting times.
If the burst of new Democratic health care reform proposals is any indication, a fresh breeze of the Obama campaign’s “Yes We Can” optimism is blowing across the nation. Mr. Obama’s team is expected to make health care one of its priorities. First out, though, was Senate Finance Committee Chair Baucus (D-MT), who introduced an aggressive health care reform package that builds on Mr. Obama’s campaign platform of cost controls and extended coverage. Senator Kennedy (D-MA) and Representatives Dingell (D-MI) and Stark (D-CA) are expected to offer proposals soon, and undoubtedly there will be others. (more…)
Category: News |
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Adam V. Russo | November 11, 2008
By Jerry Geisel, Business Insurance, November 10, 2008
Washington-The election of Barack Obama as president will change the health care legislative landscape dramatically when the Illinois Democrat takes office January.
For the first time since Bill Clinton assumed the presidency in 1993, the occupant of the Oval Office with have as a goal developing federal legislation to drastically reduce the number of people who lack health insurance. (more…)
Category: News |
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Adam V. Russo | November 11, 2008
Most lawsuits to recover damages in car accidents are resolved in state courts. State courts will order that at least a portion of the judgment be deposited into court when it appears that a health plan may have the right to reimbursement. But can a state court override the right of the health plan to recovery? This issue was addressed in Iowa Health System, Inc. v. Graham, 2008 WL 2959796 (C.D. Ill., July 30, 2008). (more…)
Category: 5th, 7th, Subrogation |
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Adam V. Russo | November 11, 2008
The U.S. District Court in North Dakota recently sorted out conflicting COB provisions of motor vehicle and health coverage. The court ruled that the motor vehicle policy had to pay its maximum benefits before the health plan began paying its benefits. In the North Dakota case, an auto policy restricted benefits to $5,000 in the event the policyholder is covered by another policy; the health plan mandated that the auto insurer must pay up to its policy limit before the plan would begin paying. The court upheld the health plan’s decision. (more…)
Category: 8th, North Dakota |
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Adam V. Russo | November 11, 2008
Motor vehicle insurance policies usually include personal injury protection (PIP) coverage that will reimburse the insured and/or a family member for a limited amount of medical expenses regardless of who was at fault. Many current motor vehicle policies limit the PIP coverage to relatively small amounts if the injured person has other health coverage. The general idea of that approach is to provide greater PIP coverage, but to permit the auto insurer to have secondary liability if the injured person has other coverage. (more…)
Category: Coordination of Benefits, Massachusetts |
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Adam V. Russo | November 10, 2008
Here is a sneak preview of Attorney Russo’s article that will be published in the Winter 2009 edition of The Subrogator
By Adam V. Russo[i]
As a subrogation attorney, sometimes I receive a case where the settlement funds are nowhere to be found. Regardless of this fact, the plan is asking me to obtain a 100% recovery three months after the settlement. While I know there is case law out there stating that plans have the right to recover even if the funds aren’t identified, the question is one of practicality. In the real world, how will you actually recover the money if you don’t know where the settlement proceeds are? Let’s say that you have a judgment in the underlying case but the patient has already spent the money; what good is the judgment when the chances of ever seeing a penny are slim? If the money is spent, regardless of your rights, what is the possibility that you will ever actually see it?
(more…)
Category: News, Subrogation |
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Adam V. Russo | November 6, 2008
By Daran Kiefer, Esq., Kreiner& Peters Co.L.P.A
This year, subrogation professionals have followed the public relations nightmare: the Debbie Shank Case. In the aftermath of the media condemnation of the ERISA plan seeking to enforce its contractual rights, we have had to deal with a lot of employers who are concerned with their subrogation efforts, not wanting them to end up as the topic of discussion on Anderson Cooper’s 360 Show on CNN. What do you do when employer sponsors want to give up subrogation despite the language in the plan calling for it? (more…)
Category: ERISA, Subrogation |
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Adam V. Russo | November 6, 2008
Robin J. Fisk, Esq., Fisk Law Firm
Inception by
In 1999, the Institute of Medicine issued a report finding that medical errors were a leading cause of mortality and morbidity in the United States, exceeding deaths attributable to motor vehicle accidents, breast cancer and AIDS.(1) The report, concluding that medi[i]cal errors contributed to 98,000 deaths per year, “ignited public and professional dialog.”(2)
Following this report, in 2002 the National Quality Forum (“NQF”),(3) an organization created to develop quality standards and measure and encourage reporting endorsed a list of 27 serious, largely preventable conditions in which, it claimed should never happen to a hospital patient.(4) A 28th was added in 2006. The list included preventable errors arising from surgery, medical devices or products; inadequate patient protection; inadequate care management; unclean or unsafe environmental conditions; or criminal acts. The intent was to create national consensus around a common set of adverse events which needed to be investigated, analyzed for root cause and reported any time they occur – and the list was the start. (more…)
Category: Never Events |
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Adam V. Russo | November 6, 2008
Based on the Supreme Court’s decisions in MetLife and LaRue, employers should consider making changes and acting proactively to implement strategies to help ensure that plan disputes are channeled through a committee and that the committee’s decisions receive deference from the courts.
Many corporate officers, employees and board members serve as ERISA fiduciaries. For a fiduciary accused of breaching its duties under ERISA, the stakes are high. ERISA Section 409 imposes personal liability on a fiduciary that breaches its duty. ERISA authorizes lawsuits against fiduciaries by participants, beneficiaries, the plan administrator, other fiduciaries ,and the U.S. Department of Labor. The federal courts have uniformly held that ERISA’s fiduciary duty is “the highest duty known to the law.” (more…)
Category: Claims Procedures, Claims Review, ERISA |
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Adam V. Russo | November 6, 2008
TPAs rely heavily on ERISA’s requirements that claimants must exhaust their administrative remedies before going to court, and when they do sue, assuming that the Plan documents grant the claim administrator the appropriate discretionary authority, they must show that the claim administrator abused its discretion when denying their claim, before any court will get to the merits of their allegations.
Few plaintiffs are able to meet these burdens, and so either don’t sue or often get their lawsuits quickly dismissed. Until recently most courts were not very sympathetic to plaintiffs’ arguments of procedural violations, but things are changing, the most significant development being the Supreme Court’s decision this summer in MetLife v. Glenn. (more…)
Category: 7th, 9th, Claims Procedures, Claims Review |
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