Louisiana to get $12M in Health Net case
National News
The Louisiana Supreme Court has ordered Health Net Inc., a major health maintenance organization, to cover more than $180 million in claims by consumers, health care providers and creditors in Louisiana, Oklahoma and Texas.
Louisiana Insurance Commissioner Jim Donelon told The Advocate that Louisiana will get the smallest portion of the payout.
"We have about $12 million coming to us to policyholders, providers and general creditors, meaning companies who sold them supplies or that rented them space," Donelon said.
Donelon said the unanimous ruling, issued Friday, will reimburse all of AmCare Louisiana HMO's members, providers, and creditors for any losses caused by Health Net's conduct.
Health Net sold health plans in the three states to AmCareco Inc. in 1999. In 2002, the troubled health plans were placed under state supervision. Each of the state's insurance departments sued AmCareco and Health Net, alleging fraud, negligence, conspiracy and breach of fiduciary duty.
In 2005, a state district court jury awarded the Texas plaintiffs around $100 million in damages. In 2005, a state judge in Baton Rouge issued similar verdicts against Health Net and awarded $30 million to the Louisiana and Oklahoma plaintiffs.
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Workers’ Compensation Subrogation of Administrative Fees and Costs
When a worker covered by workers’ compensation makes a claim against a third party, the workers’ compensation insurance retains the right to subrogate against any recovery from that third party for all benefits paid to or on behalf of a claimant injured at work. When subrogating for more than basic medical and indemnity benefits, the Texas workers’ compensation subrogation statute provides that “the net amount recovered by a claimant in a third‑party action shall be used to reimburse the carrier for benefits, including medical benefits that have been paid for the compensable injury.” TX Labor Code § 417.002.
In fact, all 50 states provide for similar subrogation. However, none of them precisely outlines which payments or costs paid by a compensation carrier constitute “compensation” and can be recovered. The result is industry-wide confusion and an ongoing debate and argument with claimants’ attorneys over what can and can’t be included in a carrier’s lien for recovery purposes.
In addition to medical expenses, death benefits, funeral costs and/or indemnity benefits for lost wages and loss of earning capacity resulting from a compensable injury, workers’ compensation insurance carriers also expend considerable dollars for case management costs, medical bill audit fees, rehabilitation benefits, nurse case worker fees, and other similar fees. They also incur other expenses in conjunction with the handling and adjusting of workers’ compensation claims. Workers’ compensation carriers typically assert, of course, that, they are entitled to reimbursement for such expenditures when it recovers its workers’ compensation lien. Injured workers and their attorneys disagree.