Cooper v. Premera Blue Cross, Slip Copy, 2008 WL 2180148 (W.D.Wash.) (May 23, 2008) addresses a risk often overlooked by plan participants when debating over their benefit plan’s right of reimbursement from other liable insurance carriers.

Cooper suffered multiple injuries while he was a passenger involved in an ATV accident and applied for benefits through his own auto carrier, Allied Insurance, because the driver’s vehicle was uninsured.  Cooper received $64,200 for medical expenses and lost wages through his PIP and UM coverage.

Cooper’s health insurance through his employer, Premera, paid medical bills related to the accident and therefore requested reimbursement from Cooper for the amount of PIP coverage available, on the basis that PIP “is an exclusion on this member’s plan.”

Cooper relied on a plan provision titled, “Third-Party Liability”, because his insurance was not a liable third party he thought that the provision would not apply; however, Premera was not upholding subrogation rights. Premera could have contended subrogation rights in a situation where Allied Insurance had not paid the PIP benefit.  Since Allied did pay in PIP benefits, Premera sought reimbursement through Allied.

In another attempt for defense, Cooper argued that he should be allowed to keep the PIP benefits because he has not been fully compensated for all of his damages but Premera was not obliged to compensate Cooper for his lost wages, pain and suffering, or any non-medical damages.  Premera’s subrogation provision does not require that plaintiff be made whole before the Plan can seek reimbursement.

Tags:

This entry was posted by Adam V. Russo on Monday, June 9th, 2008 at 2:02 pm and is filed under 9th, Coordination of Benefits, Plan Language, Subrogation. 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.