Re-Payment of Health Insurance Plans Covered by ERISA

On a weekly, if not daily, basis, plaintiff’s personal injury lawyers have to deal with subrogation interests.  Many of those subrogation claims involve the law of ERISA.  

This opinion out of the Illinois Court of Appeals addresses the issue of disputes over the amount of money to be re-paid to the holder of the subrogation interest.

Defendant had a personal injury claim.  Plaintiff sought subrogation and claimed that it was due almost $63,000.  Defendant claimed that some of the expenses sought did not arise from medical treatment caused in the incident giving rise to the personal injury claim.  Plaintiff countered with answers to interrogatories in the personal injury claim, in which Plaintiff contended that back surgery (the subject of the disputed medical claim) was related to the accident).  Defendant argued that her physicians did not causally link the back problems to the accident, and therefore Plaintiff’s subrogation interest in any future personal injury settlement or judgment proceeds should be reduced accordingly.  Plaintiff countered that one physician said the link was possible, that it determined the subrogation amount, and that under ERISA the court should defer to its decision and order that the amount of the subrogation interest include amounts for the surgery.

If you do personal injury work, you need to read the entire opinion.  However, this excerpt will give you a feel for the result:

 

This court recognizes that a court must defer to the plan administrator’s choice between competing medical opinions so long as it is rationally supported by the record evidence.  See Black,582 F.3d at 745-46, citing Semien, 436 F.3d at 812. This court concludes that there is no  rational support in the record for [Defendant] Rotech’s choice to rely on Dr. Wilson’s vague, unspecific opinion rather than Dr. Potts’ opinion.  Dr. Wilson testified that he could not give an opinion regarding whether the treatment he provided was necessary because of the collision because any such opinion “would be speculation.”  Moreover, this court concludes that Rotech could not reasonably disregard Dr. Potts’ opinion on the basis that Dr. Potts did not see Huff after July 1, 2006.  First of all, it is not true.  Dr. Potts testified that he saw Huff on August 9, 2006.  In addition, Dr. Potts provided treatment to Huff before the October 2004 accident, shortly after the accident and well into 2006, more than one and one-half years after the accident.  There is no reasoned basis for disregarding Dr. Potts’ clear, well explained opinion and accepting the vague, admittedly speculative, opinion provided by Dr. Wilson, who did not see Huff until more than one and one-half years after the accident.  This court concludes that Rotech arbitrarily refused to accept reliable evidence, the deposition testimony of Huff’s treating physician, Dr. Potts.  See Holmstrom, 615 F.3d at 774-75. Rotech ’s rejection of Dr. Potts’ testimony could only have been “based on selective readings that are not reasonably consistent with the entire picture.”  See Holmstrom, 615 F.3d at 777

 

The court also rejected the Plaintiff’s position that Defendant was judicially estopped from denying that causal relationship between her back injury and the motor vehicle wreck given her answers to interrogatories.  

 

[Defendant] Huff’s position in the circuit court case [about the relationship between the back injury and the wreck] was not successful and  she is not forever bound to her losing argument. Therefore, judicial estoppel has no application in this case. 
 
Read the opinion in Rotech Healthcare, Inc. v. Huff, No.  09-CV-224 (Il. Ct. App. March 8, 2011) here.   This opinion demonstrates the need to create an appropriate record to support a reduction in a subrogation interest.  The defendant’s lawyers did a good job fighting for their client on this issue.