ERISA and health insurance subrogation : in all 50 states / Gary L. Wickert.
2010
KF3515 .W53 2010 (Map It)
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Details
Author
Title
ERISA and health insurance subrogation : in all 50 states / Gary L. Wickert.
Published
Huntington, N.Y. : Juris Pub., [2010]
Copyright
©2010
Call Number
KF3515 .W53 2010
Edition
Fourth edition.
ISBN
9781578232758 (hbk.)
1578232759 (hbk.)
1578232759 (hbk.)
Description
1 volume (various pagings) : map ; 24 cm
System Control No.
(OCoLC)654472961
Bibliography, etc. Note
Includes bibliographical references.
Record Appears in
Portion of Title
Employee Retirement Income Security Act and health insurance subrogation
Gift
Purchased from the income of the Edith L. Fisch Fund
Gift
The Arthur W. Diamond Law Library
Purchased from the income of the Edith L. Fisch Fund
Table of Contents
Acknowledgments
xvii
About the Author
xix
Notice
xxi
How to Use This Book
xxiii
Introduction
xxvii
ch. 1
Subrogation Generally
[§] 1.01
Elements
1
[§] 1.02
Origins of Subrogation
3
[§] 1.03
Types of Subrogation
5
1.
Contractual (Conventional) Subrogation
6
2.
Equitable (Legal) Subrogation
7
a.
Difference between Subrogation and Assignment
8
b.
Roles of Equity
9
3.
Statutory Subrogation
15
a.
Workers' Compensation
15
b.
Hospital Liens
18
c.
Medicare
19
d.
Medicaid
23
e.
Interplay between Workers' Compensation and Medicare/Medicaid
29
f.
Federal Employees Health Benefit Act (FEHBA)
31
g.
Other Statutory Subrogation
31
[§] 1.04
Purposes of Subrogation
31
[§] 1.05
Anti-Subrogation Arguments
33
ch. 2
Insured Erisa-Covered Employee Welfare Benefit Plans
[§] 2.01
Generally
2
[§] 2.02
Types of Health Plans
4
1.
Indemnity Plans
5
2.
Preferred Provider Organization (PPO)
5
3.
Health Maintenance Organization (HMO)
6
4.
Individual Practice Association (IPA)
7
5.
Point-of-Service Plan (POS)
7
[§] 2.03
Multiple Employer Plans
7
1.
Single-Employer Plans
7
2.
Multi-Employer Plans
8
3.
Multiple-Employer Welfare Association Plans (MEWA)
10
4.
Voluntary Employees' Beneficiary Association (VEBA)
18
[§] 2.04
Subrogation and Reimbursement Rights
20
1.
Subrogation Rights
21
2.
Reimbursement Rights
23
3.
Standing in the Shoes of the Insured
24
4.
Indemnity versus Investment Contracts
25
5.
No Multiple Recoveries
27
6.
Subrogation Arises with Payment
28
7.
Subrogation against Municipalities
28
[§] 2.05
Requirement to Join Subrogated Party
28
1.
Wis. Stat. [§] 803.03---Claims Arising by Subrogation
29
2.
Is the Subrogated Party a Plaintiff, Defendant or Other?
30
3.
The Reverse---Must Subrogated Party Join the Insured?
30
4.
The Need to Participate
31
5.
What Do You Do If You Are Not Joined?
31
[§] 2.06
Notice to Subrogated Parties
32
[§] 2.07
What Happens If the Plaintiff Loses at Trial?
33
[§] 2.08
Made Whole Doctrine and Non-ERISA Health Plans
34
1.
Garrity v. Rural Mutual Ins. Co
36
2.
Rimes v. State Farm Mutual Auto Ins. Co
36
3.
What Does It Mean to Be "Made Whole"?
38
a.
Basic Test
38
b.
Contributory Negligence
38
4.
All Damages
46
5.
Attorney's Fees
46
6.
Where Plan Specifically Negates Made Whole Doctrine
47
[§] 2.09
Common Fund Doctrine and Non-ERISA Health Plans
54
[§] 2.10
Statute of Limitations Issues
56
[§] 2.11
Indemnification Agreements
57
[§] 2.12
Subrogated Party on the Settlement Check: Is It Enough?
58
[§] 2.13
Subrogating against Under/Uninsured Motorist Carriers
59
1.
"...A Responsible Third Party..."
59
2.
"...Any Party Who May Be Liable..."
60
3.
"...Caused, or Is Liable for..."
60
4.
Collateral Source Rules
61
5.
Anti-Subrogation Laws
64
6.
Summary
65
ch. 3
Health Insurance Subrogation in all 50 States
Introduction
1
[§] 3.01
Alabama
3
[§] 3.02
Alaska
15
[§] 3.03
Arizona
23
[§] 3.04
Arkansas
27
[§] 3.05
California
31
[§] 3.06
Colorado
49
[§] 3.07
Connecticut
55
[§] 3.08
Delaware
61
[§] 3.09
District of Columbia
65
[§] 3.10
Florida
69
[§] 3.11
Georgia
77
[§] 3.12
Hawai'i
89
[§] 3.13
Idaho
95
[§] 3.14
Illinois
101
[§] 3.15
Indiana
111
[§] 3.16
Iowa
119
[§] 3.17
Kansas
125
[§] 3.18
Kentucky
133
[§] 3.19
Louisiana
141
[§] 3.20
Maine
151
[§] 3.21
Maryland
157
[§] 3.22
Massachusetts
165
[§] 3.23
Michigan
173
[§] 3.24
Minnesota
183
[§] 3.25
Mississippi
191
[§] 3.26
Missouri
195
[§] 3.27
Montana
199
[§] 3.28
Nebraska
209
[§] 3.29
Nevada
215
[§] 3.30
New Hampshire
221
[§] 3.31
New Jersey
225
[§] 3.32
New Mexico
235
[§] 3.33
New York
241
[§] 3.34
North Carolina
257
[§] 3.35
North Dakota
263
[§] 3.36
Ohio
267
[§] 3.37
Oklahoma
279
[§] 3.38
Oregon
285
[§] 3.39
Pennsylvania
293
[§] 3.40
Rhode Island
305
[§] 3.41
South Carolina
309
[§] 3.42
South Dakota
315
[§] 3.43
Tennessee
319
[§] 3.44
Texas
327
[§] 3.45
Utah
339
[§] 3.46
Vermont
345
[§] 3.47
Virginia
349
[§] 3.48
Washington
355
[§] 3.49
West Virginia
361
[§] 3.50
Wisconsin
367
[§] 3.51
Wyoming
385
ch. 4
Self-Funded, Erisa-Covered Employee Medical Benefit Plan Subrogation
[§] 4.01
Introduction to ERISA
2
1.
History of ERISA
2
2.
Background
3
3.
Enactment and Purpose
5
4.
Scope of ERISA
6
5.
Definitions---The Language of ERISA
7
6.
Trust, Contract, and Labor Law Parallels
9
a.
Trust Law
9
b.
Contract Law
11
c.
Labor Law
12
7.
Federal Common Law
12
[§] 4.02
What Is an ERISA Plan?
14
1.
Self-Funded Plans versus Insured Plans
16
2.
Stop-Loss Coverage
22
3.
General Rule to Determine Whether Plan Is ERISA-Covered
28
4.
Safe Harbor Regulations
32
5.
Plans Not Subject to ERISA
34
a.
Government Plans and Church Plans
34
b.
Trade Association Plans and Employees' Beneficiary Associations
36
c.
Plans That Cover Owners and Not Employees
39
d.
Multi-Employer Plans
39
e.
Entities Not Engaged in Interstate Commerce
41
f.
Subrogating Insured ERISA-Covered Plans
41
6.
Other Plans Subject to ERISA
41
a.
HMO Plans
41
b.
Plans Administered by Employer
42
c.
Occupational Accident Plans
42
7.
What Constitutes the Plan?
47
a.
Coverage Booklet
47
b.
Summary Plan Description (SPD)
47
c.
Wrap Documents
48
ch. 5
Erisa Preemption
[§] 5.01
Preemption, Saving and Deemer Clauses
2
1.
Preemption Clause
4
2.
Saving Clause
8
3.
Deemer Clause
10
[§] 5.02
Two Types of Preemption---Complete and Conflict
14
1.
Complete Preemption (Narrow Preemption)
16
2.
Conflict Preemption (Broad Preemption)
20
[§] 5.03
ERISA Preemption of State Law Where Plan Is Insured and Not "Self-Funded"
23
[§] 5.04
When Does State Law "Relate to" an Employee Benefit Plan?
25
[§] 5.05
When Does State Law "Regulate Insurance"?
30
[§] 5.06
Preemption of State Court Judgments and Orders
37
[§] 5.07
Erosion of Preemption
38
ch. 6
Erisa and the Made Whole Doctrine
[§] 6.01
Introduction
2
[§] 6.02
Made Whole Doctrine as Default Rule
3
[§] 6.03
Applied to Self-Funded Plans
4
[§] 6.04
Doctrine Affected by Reimbursement Provision
10
[§] 6.05
Presumption against Made Whole Doctrine
12
[§] 6.06
Made Whole Doctrine as Gap Filler
13
[§] 6.07
Effect of Plan Administrator's Interpretation
13
[§] 6.08
Made Whole Doctrine Applicable unless Specifically Negated by Plan Language
14
[§] 6.09
Made Whole Doctrine under Federal Common Law
19
[§] 6.10
Definition of Made Whole
20
[§] 6.11
Where Beneficiary Violates Plan's Cooperation Clause
22
[§] 6.12
Made Whole Doctrine Doesn't Affect Other Duties under Plan
22
[§] 6.13
Effect of Exclusionary/Excess Language
23
[§] 6.14
Examples of Specific Plan Language
24
[§] 6.15
Treatment of Made Whole Doctrine by Circuit
26
1.
First Circuit (ME, MA, NH, Puerto Rico, RI)
26
2.
Second Circuit (NY, CT, VT)
27
3.
Third Circuit (DE, NJ, PA, Virgin Islands)
27
4.
Fourth Circuit (MD, NC, SC, VA, WV)
27
5.
Fifth Circuit (LA, MS, TX)
28
6.
Sixth Circuit (KY, MI, OH, TN)
28
7.
Seventh Circuit (IL, IN, WI)
32
8.
Eighth Circuit (AR, IA, MN, MO, NE, ND, SD)
33
9.
Ninth Circuit (AK, AZ, CA, HI, ID, MT, NV, OR, WA, Guam, Mariana Islands)
35
10.
Tenth Circuit (CO, KS, NM, OK, UT, WY)
37
11.
Eleventh Circuit (AL, FL, GA)
38
12.
D.C. Circuit (District of Columbia)
40
ch. 7
Erisa and the Common Fund Doctrine
[§] 7.01
Introduction
2
[§] 7.02
Plan Language: "Out of Any Monies Recovered" and "All Rights of Recovery"
3
[§] 7.03
"Full Reimbursement" Language
4
[§] 7.04
Absence of Language Exempting Common Fund Doctrine
4
[§] 7.05
Plan Language Clearly Exempts Common Fund Doctrine
10
[§] 7.06
Effect of Plan Administrator's Interpretation
12
[§] 7.07
Common Fund Doctrine under Federal Common Law
12
[§] 7.08
Hourly or Contingency Fee?
14
[§] 7.09
Notice of Litigation Requirement
15
[§] 7.10
Who May Raise a Common Fund Claim?
16
[§] 7.11
Treatment of Common Fund Doctrine by Circuit
17
1.
First Circuit (ME, MA, NH, Puerto Rico, RI)
18
2.
Second Circuit (NY, CT, VT)
19
3.
Third Circuit (DE, NJ, PA, Virgin Islands)
19
4.
Fourth Circuit (MD, NC, SC, VA, WV)
19
5.
Fifth Circuit (LA, MS, TX)
20
6.
Sixth Circuit (KY, MI, OH, TN)
20
7.
Seventh Circuit (IL, IN, WI)
21
8.
Eighth Circuit (AR, IA, MN, MO, NE, ND, SD)
22
9.
Ninth Circuit (AK, AZ, CA, HI, ID, MT, NV, OR, WA, Guam, Mariana Islands)
23
10.
Tenth Circuit (CO, KS, NM, OK, UT, WY)
23
11.
Eleventh Circuit (AL, FL, GA)
24
12.
D.C. Circuit (District of Columbia)
26
ch. 8
Rights of Recovery: Subrogation and Reimbursement
[§] 8.01
Introduction
2
[§] 8.02
Persons Who Can Pursue Subrogation
3
[§] 8.03
Venue
7
[§] 8.04
Parties Authorized to Bring Action
9
[§] 8.05
Jurisdiction
11
[§] 8.06
Removal
17
[§] 8.07
Problem Circuits
26
[§] 8.08
Abstention
29
[§] 8.09
Intervention
30
1.
State Court
30
2.
Federal Court
34
[§] 8.10
ERISA Statutory Authority Subrogation Enforcement
35
[§] 8.11
Rights of Recovery: Subrogation and Reimbursement
36
1.
Recovery Rights Generally
36
2.
Plan Language Determines Subrogation Rights
38
3.
Recovery Rights under ERISA
39
4.
Types of Recovery Provisions
40
a.
Subrogation Provisions
40
b.
Reimbursement Provisions
41
c.
Exclusionary Provisions
42
d.
No Subrogation Language
43
5.
Subrogation Receipts and Reimbursement Agreements
44
a.
Subrogation Agreement Does Not Control
45
b.
Subrogation Agreement Does Control
46
6.
Recovery Priorities
49
a.
Elements of Damages Recovered
49
b.
Allocation of Recovery among Beneficiaries
59
c.
First Money Recovered
64
d.
Subrogating for More Than Benefits Paid
64
e.
Gray Areas
65
f.
Causation
65
7.
Reimbursement Rights
68
8.
Sample ERISA Plan Subrogation Language
70
9.
Sue in the Name of Plan or Third Party Administrator?
71
10.
Credit against Future Benefits
72
11.
Summary Plan Description (SPD)
79
12.
Summary Plan Description as Formal Plan Document
84
13.
Plan Fiduciary's Interpretation of Plan Language
88
14.
Multiple Plan Documents-Conflicting Terms
94
15.
Purpose of ERISA Subrogation
96
[§] 8.12
Injuctions
97
[§] 8.13
Constructive Trusts and Equitable Liens
98
[§] 8.14
Restitution
102
[§] 8.15
Declaratory Judgment Actions
108
[§] 8.16
What Constitutes "Appropriate Equitable Relief"?
112
[§] 8.17
Early Decisions
116
ch. 9
Supreme Court Decisions Affecting Erisa Reimbursment: Knudson and Sereboff
[§] 9.01
Great West Life & Annuity Ins. Co. v. Knudson
1
[§] 9.02
Why the Supreme Court Got It Wrong in Knudson
5
[§] 9.03
Sereboff v. Mid Atlantic Medical Services, L.L.C.
8
[§] 9.04
Applying Knudson and Sereboff to ERISA Subrogation
12
[§] 9.05
Treatment of Knudson by Circuit
15
1.
First Circuit (ME, MA, NH, Puerto Rico, RI)
17
3.
Third Circuit (DE, NJ, PA, Virgin Islands)
21
4.
Fourth Circuit (MD, NC, SC, VA, WV)
23
5.
Fifth Circuit (LA, MS, TX)
26
7.
Seventh Circuit (IL, IN, WI)
30
8.
Eighth Circuit (AR, IA, MN, MO, NE, ND, SD)
32
9.
Ninth Circuit (AK, AZ, CA, HI, ID, MT, NV, OR, WA, Guam, Mariana Islands)
36
10.
Tenth Circuit (CO, KS, NM, OK, UT, WY)
39
11.
Eleventh Circuit (AL, FL, GA)
39
12.
D.C. Circuit (District of Columbia)
45
[§] 9.06
Summary of Supreme Court Treatment of "Appropriate Equitable Relief"
47
[§] 9.07
Possible Congressional Action to Remedy Knudson
51
ch. 10
Other Erisa Recovery Issues
[§] 10.01
Medical Malpractice Recoveries
2
[§] 10.02
Uninsured Motorist Benefits
3
[§] 10.03
Med Pay and PIP Benefits
15
[§] 10.04
No-Fault Insurance Laws
16
[§] 10.05
Anti-Subrogation Laws
18
[§] 10.06
"Regulation of Insurance" Test
24
[§] 10.07
Lien Reduction Statutes
26
[§] 10.08
Common Fund Doctrine Statutes
26
[§] 10.09
State Collateral Source Rules
31
[§] 10.10
Federal Employees Health Benefit Act (FEHBA)
37
[§] 10.11
Other State Statutes
45
[§] 10.12
Federal Common Law
46
[§] 10.13
Laws regarding Minors
48
[§] 10.14
Recovery of Benefit Payments Made by Mistake
49
1.
Mistake of Fact
51
2.
Mistake of Law
52
3.
Overpayment of Benefits (Social Security)
52
[§] 10.15
Coordination of Benefits (COB)
56
[§] 10.16
NAIC Group Coordination of Benefits Model Regulation
73
[§] 10.17
HIPAA, HITECH, Medical Privacy, and Subrogation
76
1.
The Problem: Medical Record Privacy
76
2.
The Solutions: HIPAA's and HITECH's Privacy Regulations
77
3.
HIPAA's and HITECH's Impact on Subrogation
78
4.
The Federal Services Modernization Act (FSMA)
81
5.
Summary
83
[§] 10.18
Overlap with Workers' Compensation
83
[§] 10.19
Attorney's Fees
96
[§] 10.20
Choice-of-Law Provisions
101
[§] 10.21
Statutes of Limitations
102
[§] 10.22
Right to Jury Trial
104
[§] 10.23
Equitable Estoppel
104
[§] 10.24
Bankruptcy
104
[§] 10.25
Bad Faith
114
ch. 11
Enforcement of Reimbursement Rights After Settlement
[§] 11.01
Introduction
1
[§] 11.02
Federal Court Jurisdiction
2
[§] 11.03
Unjust Enrichment
3
[§] 11.04
Effect of Release of Third Party by Participant
7
[§] 11.05
Tortious Interference
9
[§] 11.06
Conversion
10
[§] 11.07
Equitable Lien by Agreement
11
[§] 11.08
Implied Partnership
12
[§] 11.09
Breach of Fiduciary Duty
14
[§] 11.10
Breach of Contract
15
[§] 11.11
State Court Jurisdiction after Knudson and Sereboff
23
1.
Narrow View
26
2.
Broad View
28
3.
Modern View
28
[§] 11.12
Plaintiffs' Attorneys' Ethical Considerations
29
[§] 11.13
Special Needs Trusts
30
ch. 12
Improving Plan Language
ch. 13
Hiring Subrogation Counsel
APPENDICES
A-1.
Wis. Stat. [§] 803.03 - Joinder of Persons Needed for Just and Complete Adjudication
1
A-2.
29 U.S.C. [§] 1102 - Establishment of Plan
5
A-3.
Bad ERISA Plan Subrogation Language
7
A-4.
Good ERISA Plan Subrogation Language
9
A-5.
29 U.S.C. [§] 1003 - Coverage
13
A-6.
29 U.S.C. [§] 1144 - Other laws
15
A-7.
Geographic Boundaries of United States Courts of Appeals and United States District Courts
21
A-8.
29 U.S.C. [§] 1132 - Civil enforcement
23
A-9.
28 U.S.C. [§] 1331 - Federal question
33
A-10.
Form 5500 - Annual Return/Report of Employee Benefit Plan
35
A-11.
Sereboff v. Mid Atlantic Medical Service, Inc.
39
A-12.
Great-West Life & Annuity Ins. Co. v. Knudson
53
A-13.
Curriculum Vitae of Gary L. Wickert
83