While their ads are filled with words like care, protection and trust, you have to wonder if the only thing that you can trust about insurance companies these days is that they only care about protecting their own money. The complicated law of ERISA not only makes it easier for insurance companies to deny paying benefits, it also makes it easier for them to go after the very people they insure for repayment of benefits that they have already paid. This recent Washington Post article tells a disturbing story about a Blue Cross entity going after its own insured for $9,000. As the story points out, the insurance company paid for the woman’s medical care then reversed course. Now it wants the money that it paid back from her.
More and more frequently we see examples of a health insurance company arguing that it needs to be paid back because of what it suddenly considers an “overpayment.” This is in addition to insurance companies trying to use onerous reimbursement and subrogation provisions to try to take most or even all of an injured person’s personal injury settlement.
In most of these cases, it is debatable whether or not the insurance company is acting legitimately.
Before you know whether or not they are entitled to your money, you first and foremost have to examine the health insurance contract and see how the Plan is funded and what is the language of the Plan. Then, there is extensive case law dealing with the principles of equity and the law of trusts that govern ERISA plans.
To make it even more complicated, the law is constantly changing. The Washington Post story deals with a Federal Employee Healthcare Benefits claim, which was the subject of an 8th circuit ruling today. Most health insurance plans are ERISA plans, which is the subject of a U.S. Supreme Court case that hopefully will clarify a lot of these issues and help level the playing field for consumers.
In the meantime, if your insurance company is seeking an overpayment, reimbursement or subrogation, talk with a lawyer who knows the law.