Self-insured medical plans typically contain “subrogation clauses” that allow the plan to claim reimbursement from a personal injury recovery of a participant. The self-insured plan’s reimbursement right exists even if state laws prohibit such attachment as ERISA pre-empts the state limitation. For example, the Supreme Court ruled that ERISA trumped Pennsylvania’s anti-subrogation law allowing a self-insured plan to recoup payments it made for medical expenses from an injured participant’s tort recovery.
Recently in its decision in Sereboff v. Mid Atlantic Medical Services, Inc., the U.S. Supreme Court unanimously affirmed a self-insured health plan’s legal right of reimbursement from a participant’s personal injury recovery. Enforcement of this right requires that the plan sponsor include reimbursement language in both its plan document and summary plan description. Specifically, well-drafted documents should address the following:
- Identifying the individuals covered by the reimbursement right in addition to the participant (e.g., dependents, heirs, etc.).
- Specifically reference the right of subrogation and reimbursement.
- Specifically reject common law doctrines such as the "make whole" and "common fund" doctrines.
- State that the plan has a first priority equitable lien with respect to any proceeds (from any source) that will be held in a "constructive trust" for the benefit of the plan and that the participant consents to both the lien and the constructive trust.
- Require participant cooperation with respect to the plan’s ability to enforce its rights, including requiring participants to execute subrogation and reimbursement agreements as a condition to receiving benefits.
- Specifically reference the plan’s right to offset future benefits to the participant.
Properly drafted (and consistent) language in plan documents and summary plan descriptions will serve to thwart any efforts to block the enforcement of a self-insured plan’s reimbursement rights. However, a medical plan’s action in seeking reimbursement from an employee or dependent may not be without other repercussions.
Substantial adverse publicity and damage to employee relations could result when medical plans seek to recoup payments from accident victims. Consider the media firestorm that rained down on Wal-Mart after it tried to recoup $470,000 in medical reimbursements from a $1 million tort recovery of an injured employee. Wal-Mart’s was tarred with the title of “Worst Person in the World” from one media pundit. Ultimately, the Wal-Mart plan relented allowing a brain-damaged former employee to keep the money, even though Wal-Mart probably had a clear legal right to reimbursement.