Medicare Advantage Insurers Primary Payers for Accident Expenses Class Action

This is one of a number of recent class actions brought by Medicare-related entities, trying to recover payments that insurance companies offering Medicare Advantage allegedly should have paid. The complaint claims that the insurance companies “have systematically and uniformly failed to honor their primary payer obligations under the Medicare Secondary Payer provisions of the Social Security Act (the ‘MSP Law’) … by failing to reimburse medical expenses resulting from injuries sustained in automobile and other accidents.”

The list of defendants in this case is long, including Northland Insurance Company, Travelers Casualty Company, Farmington Casualty Company, Travelers Casualty and Surety Company, Standard Fire Insurance Company, Select Insurance Company, St. Paul Fire and Marine Insurance Company, St. Paul Mercury Insurance Company, Charter Oak Fire Insurance Company, Phoenix Insurance Company, Travelers Indemnity Company, Travelers Casualty and Surety Company of America, Travelers Property Casualty Insurance Company, Travelers Home And Marine Insurance Company, and First Floridian Auto and Home Insurance Company.

Private insurance companies like these are allowed to offer Medicare Advantage policies under Part C of Medicare. Under these plans, Medicare pays the companies a fixed amount per enrollee, and the companies then become the primary payer, providing “at a minimum, the same benefits that Enrollees would receive under traditional Medicare.”

The complaint contends that the defendants listed above should have been the primary payer of accident-related medical expenses suffered by their enrollees. Medicare is supposed to be the secondary payer.

But the complaint alleges that these companies did not fulfill their obligations: It says they “have failed to reimburse [Medicare organizations and others] for accident-related medical expenses upon entering into settlements with Medicare beneficiaries. As a result, the cost of these accident-related medical expenses has been borne by Medicare and MA [Medicare Advantage] Plans to the detriment of the Medicare Trust Funds and the public.”

The complaint says that the plaintiffs and class members in this case “are entitled to be paid or reimbursed at industry standard rates by the defendant primary payers.” It claims they “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”—which is the aim of this class action.

The class for this action is Medicare Advantage Plans and downstream parties or assignees who have made a conditional payment for benefits from Medicare Part C, in the US and its territories, who paid for the medical expenses of an enrolled person where any of the defendants in this case

  • Was the primary payer because it settled a claim with a person enrolled in a Medicare Advantage Plan
  • Settled a dispute about paying medical expenses with such a person, and
  • Did not reimburse Medicare Advantage Plans and downstream parties or assignees for the conditional payments when they settled with the person.
Article Type: Lawsuit
Topic: Insurance

Most Recent Case Event

Medicare Advantage Insurers Primary Payers for Accident Expenses Class Action

October 12, 2020

This is one of a number of recent class actions brought by Medicare-related entities, trying to recover payments that insurance companies offering Medicare Advantage allegedly should have paid. The complaint claims that the insurance companies “have systematically and uniformly failed to honor their primary payer obligations under the Medicare Secondary Payer provisions of the Social Security Act (the ‘MSP Law’) … by failing to reimburse medical expenses resulting from injuries sustained in automobile and other accidents.”

Medicare Advantage Insurers Primary Payers for Accident Expenses Class Action

Case Event History

Medicare Advantage Insurers Primary Payers for Accident Expenses Class Action

October 12, 2020

This is one of a number of recent class actions brought by Medicare-related entities, trying to recover payments that insurance companies offering Medicare Advantage allegedly should have paid. The complaint claims that the insurance companies “have systematically and uniformly failed to honor their primary payer obligations under the Medicare Secondary Payer provisions of the Social Security Act (the ‘MSP Law’) … by failing to reimburse medical expenses resulting from injuries sustained in automobile and other accidents.”

Medicare Advantage Insurers Primary Payers for Accident Expenses Class Action
Tags: Auto-Related Accident, Health Insurance, Insurance, Medicare Advantage Insurance Plans