Amica Mutual Medicare Advantage Accident Claims Class Action

This class action against Amica Mutual Insurance Company in its role as a Medicare Advantage insurer. The complaint alleges that Amica has refused to pay accident-related medical expenses, despite their role as primary payers for those enrolled under Medicare Advantage (MA) plans. This leaves Medicare, which was supposed to be the secondary payer, to pay the entire bills.

Medicare Part C allows those on Medicare to obtain their medical insurance from a private insurance company, for example Amica, through an MA plan. In this arrangement, Medicare pays Amica a fixed amount per insured. In return, Amica becomes the primary insurer for that person and must cover at least what Medicare ordinarily covers. Medicare then becomes the secondary insurer.

However, the complaint for this class action alleges that Amica has failed “to pay for or reimburse medical expenses resulting from injuries sustained in automobile and other accidents…. As a result of [Amica’s] misconduct, those accident-related medical expenses were paid by Medicare Advantage Organizations” (MAOs) and others.

The complaint claims that Amica has also failed to reimburse people “for accident-related medical expense upon entering into settlements with Medicare beneficiaries. As a result, the cost of those accident-related medical expenses has been borne by Medicare and MA Plans to the detriment of the Medicare Trust Funds and the public.”

Both in their contractual obligations and under state law, Amica is expected to cover accident-related medical expenses on a “no-fault” basis, that is, no matter who is at fault in the accident. The complaint claims, “In the case of automobile and other accidents specifically involving Enrollees of MA Plans, [Amica’s plans are] considered” the enrollees primary plans.

According to the complaint, “MA Plans stand on the same footing as traditional Medicare, including under the MSP Law, which declares that Medicare is a ‘secondary payer’ to all other sources of coverage and, consequently, are empowered to recoup from rightful primary payers when they have paid for services that fell within overlapping insurance maintained by Enrollees with a primary payer.”

The plaintiffs in this case are limited-liability companies (LLCs) assigned to recover from primary payers when necessary.

The complaint defines two classes, a Contractual Obligations Class and a Settlement Class.

The definitions are long and can be found in full on pages 22-23 of the complaint, linked below. Basically, they include all Medicare Advantage Plans and downstream actors (or their assignees) that have had to pay for medical services or expenses that should have been otherwise covered. The class period for the Contractual Obligations Class is from October 2, 2014 to the present.

Article Type: Lawsuit
Topic: Insurance

Most Recent Case Event

Amica Mutual Medicare Advantage Accident Claims Complaint

October 2, 2020

This class action against Amica Mutual Insurance Company in its role as a Medicare Advantage insurer. The complaint alleges that Amica has refused to pay accident-related medical expenses, despite their role as primary payers for those enrolled under Medicare Advantage (MA) plans. This leaves Medicare, which was supposed to be the secondary payer, to pay the entire bills.

Amica Mutual Medicare Advantage Accident Claims Complaint

Case Event History

Amica Mutual Medicare Advantage Accident Claims Complaint

October 2, 2020

This class action against Amica Mutual Insurance Company in its role as a Medicare Advantage insurer. The complaint alleges that Amica has refused to pay accident-related medical expenses, despite their role as primary payers for those enrolled under Medicare Advantage (MA) plans. This leaves Medicare, which was supposed to be the secondary payer, to pay the entire bills.

Amica Mutual Medicare Advantage Accident Claims Complaint
Tags: Health Insurance, Insurance, Nonpayment of Benefits