This past April, in a 5-to-4 decision, the United States Supreme Court ruled in favor of an injured airline mechanic and against his employer. The case involving airline mechanic, James E. McCutchen, arose from a car accident in which he was badly injured. His employer, US Airways, paid his medical expenses of $66,866. Mr. McCutchen sued the other driver and received a settlement totaling $110,000. Forty percent of that went to his lawyers, leaving him with $66,000, or a little less than US Airways had paid though its health plan. Under the terms of the plan, Mr. McCutcheon was obligated to reimburse the plan for what it had paid out if he recovered money from a third party. The question before the court was whether US Airways was entitled to the entirety of Mr. McCutcheon's settlement after attorney's fees or something less.
In finding in favor of Mr. McCutchen, the Court ruled that, absent specific language to the contrary, health plans must account for lawyers' fee and expenses incurred in obtaining settlement proceeds. "Third-party recoveries," the court wrote, "do not often come free: To get one, an insured must incur lawyers' fees and expenses. Without cost sharing, the insurer free rides on its beneficiary's efforts — taking the fruits while contributing nothing to the labor. Odder still, in some cases indeed, in this case — the beneficiary is made worse off by pursuing a third party."
"US Airways claimed $66,866 in medical expenses," the court added. "That would put McCutchen $866 in the hole; in effect, he would pay for the privilege of serving as US Airways' collection agent."
This case emphasizes the importance of closing reviewing a health plan's terms of coverage. Absent clear, concise, and comprehensive plan terms negating equitable doctrines such as "make-whole" and "common fund" doctrines, courts may use these doctrines to interpret a plan's terms. The "make'whole" doctrine stands for the proposition that an insurer may not receive any of the proceeds from the settlement of a claim, except to the extent that the settlement funds exceed the amount necessary to fully compensate the insured for the loss suffered. Only after the insured has been fully compensated for all the loss the insurer acquires a right to subrogation or is entitled to enforce its subrogation rights. The "common fund" doctrine refers to the principle that a party who creates, discovers, increases, or preserves a fund to which others also have a claim is entitled to recover litigation costs and attorney's fees from that fund. A court's use of these doctrines to interpret a health plan usually acts to substantially reduce or eliminate the plan's right to any recovery from an injured victim's settlement proceed, thus maximizing that injured person's ultimate recovery.
If you or a loved one has been the victim of another's negligence and have questions of how reimbursement of medical insurance may ultimately impact any final recovery, please give us a call for a free consultation about your rights.