In the case of Graphic Communications National Health and Welfare Fund v. Tackett, 2008 WL 2020504 (S.D.Ill.) (May 09, 2008), the District Court held that workers’ compensation awards are subject to ERISA plan reimbursement rights, to protect the Plan and the plan participants and prevent undue cost shifting.

Roy F Harmon III tells us the story of an employee injured at work, who files with the workers’ compensation carrier, and whose claim is denied by the carrier.  The employee files with the health plan, advising them of the carrier’s denial, and the Plan dutifully pays the claims.  Only then does the employee retain and attorney, appeal the carrier’s denial, and obtain settlement funds from the workers’ compensation carrier. http://healthplanlaw.com/?p=627#more-627

Harmon explains that costs are shifted to health plans when workers’ compensation carriers deny, direct the claimants to file with their health plans, and if and when the workers’ compensation carrier’s denial is appealed and settled, they never inform the health plans.  The Plan goes unreimbursed, and either the carrier avoids paying claims they are responsible for, providers are paid twice for the same claims, or the insured pockets the funds.

Fortunately, in this case, the court recognized the scenario described above and held that the Plan was due reimbursement from the carrier.

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This entry was posted by Adam V. Russo on Wednesday, June 4th, 2008 at 3:56 pm and is filed under 7th. 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.