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The Wagner Law Group Description 

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established in 1996, The Wagner Law Group has 23 attorneys engaged exclusively in employee benefits, estate planning and employment law. Seven of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.

 

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Florida Office 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

San Francisco Office

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104

 

www.wagnerlawgroup.com

 

 

 

 

February 20, 2014

 

 State and Federal Law Alert

 

 

 

 Welfare Plan Not Entitled to Recoup Mistaken Payments Made to Hospital

 

 

 

The United States Court of Appeals for the Seventh Circuit recently reviewed whether a self-funded group health plan was entitled to recoup erroneous payments it made to a hospital for a patient's treatment expenses when it discovered that the patient was not covered by the plan. In deciding Kolbe & Kolbe Welfare Plan v. Medical College of Wisconsin, the Seventh Circuit ruled that the health plan could not recover the payments.

 

An employee who participated in his employer's self-funded group health plan had a daughter in 2007. The employee submitted an enrollment form to have his newborn daughter covered by the plan.

 

The employer subsequently determined that the employee's enrollment form was incomplete and failed to provide certain information needed to determine the daughter's eligibility for enrollment. The employer requested additional information without success, and eventually denied enrollment status to the daughter in 2008. In the interim, the daughter had received over $1.7 million in medical treatment, all of which was paid for by the plan.

 

After denying the daughter's enrollment, the employer asked the hospital to refund the money it had paid for the daughter's treatment. When the hospital refused, the employer sued to recover the payments.

 

The employer asserted that ERISA allows a plan fiduciary to bring an equitable claim to enforce the terms of the plan, and that in filing the lawsuit, the employer sought to enforce the plan's overpayment provision, which provided for the recovery of payments made in error. The plan's overpayment provisions, however, limited the source of recovery to "covered persons."  The district court dismissed the plan's ERISA claim, ruling that neither the hospital, which provided medical services, nor the employee's daughter, who was denied enrollment in the plan, were "covered persons." The employer then appealed to the Seventh Circuit.

 

After reviewing the facts of the case, the Seventh Circuit upheld the decision. The Court noted that it took the employer over 11 months to figure out that the daughter was ineligible for plan coverage. It then ruled that it was not the hospital's responsibility to refund the money simply because the plan sponsor failed to keep its records straight.

 

 

 

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Pursuant to Internal Revenue Service Circular 230, we hereby inform you that any advice set forth herein with respect to US federal tax issues is not intended or written by The Wagner Law Group to be used and cannot be used, by you or any taxpayer, for the purpose of avoiding penalties that may be imposed on you or any other person under the Internal Revenue Code.

 

This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.