The fact that an individual had medical treatment for a condition before an accident and subsequently suffered an injury that required additional treatment should not defeat a plan’s right to reimbursement for benefits paid on account of the treatment resulting from the accident. A U.S. District Court reached that conclusion in Schaffer v. Mancini, 2007 WL 2725569 (N.D. N.Y., Sept. 13, 2007). 

The Facts

Palma Mancini fell on ice in a parking lot and apparently injured her left knee. She underwent surgery and incurred other expenses. She was covered by a multi-employer plan that was subject to ERISA, which paid about $9,100 on account of that medical treatment. She asserted a claim against the owner of the parking lot and recovered $18,000 either by way of settlement or judgment. The plan sought reimbursement of the benefits it paid, which she refused to pay, alleging that she had previous treatment for degenerative conditions for her knee and back, so the surgery and other treatments she received were as a result of her prior condition, and not directly caused by the fall. The plan moved for summary judgment.

The Decision

The court acknowledged that there was “limited evidence” that Mancini had a pre-existing degenerative conditions related to her knee, but concluded that there was substantial evidence that the surgery was due to the traumatic injuries cause by her fall because the degenerative conditions had not previously caused her any problems. Thus, the plan was entitled to reimbursement of the benefits it paid based on its terms and provisions.

Implications

Generally, the fact that a person has medical problems that were exacerbated by an accident would not limit liability of the person who caused the accident. Accordingly, it would appear that the court correctly resolved the plan’s claim for reimbursement of the benefits it paid. But for the accident, it did not appear that Mancini would have needed knee surgery and the other treatment she required.

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This entry was posted by Adam V. Russo on Monday, April 21st, 2008 at 4:29 pm and is filed under 2nd. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.