Mississippi ERISA medical claims and Small Claims Court

[Redemptionman]

Jurisdiction

Mississippi

I have a question and am not sure of legalities involved in it, I had health insurance through a self funded ERISA plan. This plan paid roughly 12k out on me in medical claims and payments. I paid an equal amount of around 11k with deductibles and co insurance. They use a TPA to administrator the plan and of course the TPA came back spouting ERISA to get their $12k back. I am very busy and do not have time to deal with this every day. The TPA will not deal with me and wants to deal with my attorney. Which is okay fine with me, so we asked them to remove claims unrelated to the injury that they are seeking reimbursement for. They kept playing BS games saying that they could not just reduce them blah blah blah. Ok finally I said screw it pay them 11k which is roughly what they reduced it to by removing a claim off the report.

I want to sue the TPA in small claims court for my Co pays and the amount of money unrelated to the treatments that they are seeking reimbursement for. I am not sure for what amount yet probably somewhere from 3-5K for reimbursement for my time. Besides the TPA just being a big piece of garbage what are my chances to succeed?

Anyone ever done this before and been successful?

 

[adjusterjack]

TBH, I wasn't sure what was going on until I read the following article:

ERISA liens and self-funded plans

www.advocatemagazine.com

You should read it.

There's nothing for you to sue for. You're not entitled to any money for your "time." Nobody ever is.

And your copays and deductible have nothing to do with the amount of reimbursement that the plan is entitled to.

 

[Tax Counsel]

I don't see any liability on the part of the insurer or TPA that is related to your co-payments or for money you paid for things unrelated to the issue in dispute. The real dispute you have with them is over the $11k you paid. If, as I expect, you signed a settlement agreement for this that bars any future claims on the issue there is nothing more to get. If you didn't sign a settlement agreement and never took the issue to court perhaps you may win the money back in a refund suit. Your attorney should be able to tell you whether that may be feasible.

 

[Redemptionman]

The only liability they have is to have accurate claims, roughly 2-5 of their claims that they are seeking reimbursement for are unrelated to the injury and should have been deducted. They deducted one claim but I do not think it is worth my time to sue them. I have sent funds to them to cover it but yes it deals with a self funded ERISA plan. I have since switched to my wife's plan and it is self insured which they could not do this except for the self funded part. I have sent them the money asked for a review for the 1-2k worth of claims that are in actual dispute.

I have been kicking around sending them a small claim but it probably isn't worth it since there are basically 2-3 major health insurance companies now who own 99 percent of the market. It would be interesting to see how it would have came out but I am not in the position to waste my time on it or them.

Thank you for the replies.

 

[Tax Counsel]

I have been kicking around sending them a small claim but it probably isn't worth it since there are basically 2-3 major health insurance companies now who own 99 percent of the market. It would be interesting to see how it would have came out but I am not in the position to waste my time on it or them.

Thank you for the replies.

IMO you made the right decision. It's aggravating to have these kinds of things happen, but it makes it worse to dwell on it and, as you said, waste your time on it.

 

[hrforme]

what was this "injury"? Was it work related or related to some type of accident?

Sounds like they think they paid when another insurance should have covered.

You might need to explain a little more on exactly what wasn't covered and why.

(been in benefits for a long time, but never self-funded, but it's odd that they would request claims back unless they have a very specific reason)

IANAL, but your deductible and copays were always your responsibility no matter whether the rest of the claim was paid or not

 

[Redemptionman]

what was this "injury"? Was it work related or related to some type of accident?

Sounds like they think they paid when another insurance should have covered.

You might need to explain a little more on exactly what wasn't covered and why.

(been in benefits for a long time, but never self-funded, but it's odd that they would request claims back unless they have a very specific reason)

IANAL, but your deductible and copays were always your responsibility no matter whether the rest of the claim was paid or not

They request claims back because they can and use a twist in the ERISA law to claim that medical claims are in fact employee benefits and when they are structured into a pool of self funded payments then in effect it makes these benefits fall under federal law and the federal judges being the way they are can side step state laws and indeed seek these payments made from the plan to the injured employee. So, in essence while they limit it to 3rd party recovery these self funded plans unscrupulously can get plan monies back from settlements from the injured. In several cases for severe injuries companies such as Wal Mart can get the majority of their money back, leaving the accident victim with little to no funds.

The TPA in this case removed the claim and agreed to settle. It is a clear indication that you should read your plan documents for health care, specifically the SPD. This will tell you whether or not ERISA applies and if the fund is self insured or self funded.

 

[hrforme]

They request claims back because they can and use a twist in the ERISA law to claim that medical claims are in fact employee benefits and when they are structured into a pool of self funded payments then in effect it makes these benefits fall under federal law and the federal judges being the way they are can side step state laws and indeed seek these payments made from the plan to the injured employee. So, in essence while they limit it to 3rd party recovery these self funded plans unscrupulously can get plan monies back from settlements from the injured. In several cases for severe injuries companies such as Wal Mart can get the majority of their money back, leaving the accident victim with little to no funds.

The TPA in this case removed the claim and agreed to settle. It is a clear indication that you should read your plan documents for health care, specifically the SPD. This will tell you whether or not ERISA applies and if the fund is self insured or self funded.

But those claims HAVE already been paid through a settlement with someone such as another insurance company..... Why should the injured (you) get the benefit of double payment? Isn't part of the settlement the cost of those medical claims? Not sure how this is "unscrupulous"....the injured person (you) and (your) their legal counsel should take into account that part of the settlement can (and will) go back to someone who has already paid part of their injury expenses. I'm not sure how you or your attorney has missed this.....

I've gotten many requests over the years for employees injured outside of work that is settling elsewhere regarding costs paid (such as used PTO, benefit claims, etc). This isn't new.

 

[Redemptionman]

But those claims HAVE already been paid through a settlement with someone such as another insurance company..... Why should the injured (you) get the benefit of double payment? Isn't part of the settlement the cost of those medical claims? Not sure how this is "unscrupulous"....the injured person (you) and (your) their legal counsel should take into account that part of the settlement can (and will) go back to someone who has already paid part of their injury expenses. I'm not sure how you or your attorney has missed this.....

I've gotten many requests over the years for employees injured outside of work that is settling elsewhere regarding costs paid (such as used PTO, benefit claims, etc). This isn't new.

Lol, why not subrogate against the third party who is 100 percent responsible for the injury? I paid as much as the inusrance company has so there is no double payment. These liens or plans in certain situations could bar someone from bringing a suit against a third party so how are they going to pay them back then? Most states have laws against first person subrogation. This deals with medical insurance not PTO or 401k fsa contributions. This is certainly a newer process since it has only become prominent in the past 30 years or so.