8. Jefferson-Pilot Life Insurance Company v. Krafka, 50 Cal.App.4th 190 (1996)
Insurance company's claim for reimbursement under a group health plan governed by ERISA is preempted. State courts have no jurisdiction over such claims.
9. Evanston Hospital v. Hauck, 1F.3d 540 (7th Cir. 1993)
The court here held that under a state Medicaid program funded by federal Medicaid funds, a hospital or other provider was barred from accepting state Medicaid benefits and then pursuing the patient for the balance over the amount paid by Medicaid. The court expressly held that if there is a windfall created by this situation, that windfall was intended to go to the personal injury victim and not the medical provider.
10. Mercy Hospital and Medical Center v. Farmers Insurance Group, 15 Cal.4th 213 (1997) The Court here held that a hospital lien claimant could not recover more than 50% of the gross recovery under the available policy limits from the tortfeasor's insurance carrier despite the fact that said carrier had paid its policy limits without honoring the lien. The Court also noted that the hospital's lien rights were not exclusive.
11. PacifiCare v. Martin, 34 F.3d 834 (9th Cir. 1994)
The Ninth Circuit here held that an employer’s group health insurance plan did not state a proper cause of action under ERISA for enforcement of its reimbursement agreement against its insured who had recovered on his third party case against the tortfeasor. The basis for the decision in PacifiCare was that the federal law of ERISA (29 USC §1132(a)(3)) only allows a suit by a fiduciary "to obtain other appropriate equitable relief . . . to enforce any provisions of this subchapter or the terms of the plan." The court held that it had consistently refused to recognize common law causes of action in ERISA. NOTE: Normally, the carriers attempt to get around this requirement by suing for restitution and/or unjust enrichment. It is interesting to note that Judge Norris in his dissent indicated that the district court had correctly characterized the PacifiCare claim for reimbursement "as an equitable claim for unjust enrichment." Although this issue is not addressed in the majority opinion, if this statement in the dissent is correct then this case would appear to support an argument that the Ninth
Circuit would not recognize a claim of unjust enrichment in these circumstances under the law of ERISA.
12. FMC Medical Plan v. Owens, 122 F.3d 1258 (9th Cir. 1997)
The Ninth Circuit here held that an insurance carrier's claim for reimbursement from its insured's personal injury recovery was a contract claim for damages not allowable under ERISA (29 USC §1132(a)(3)). The court held that to qualify as equitable relief under §1132(a)(3), restitution would require that the claimant has obtained the payments from the plan through fraud or other misconduct. The court suggested in footnote 2 that the carrier can sue for this relief in state court, which would likely violate the rule of complete preemption and exclusive federal jurisdiction previously adopted by the Supreme Court in Pilot Life v. Dedeaux, 107 S.Ct. 1549 (1987) and Metropolitan Life v. Taylor, 107 S.Ct. 1542 (1987). See also Bast v. Prudential.
Mark C. Blane is a San Diego Auto Accident Attorney, and the managing lawyer of the Law Offices of Mark C. Blane, a San Diego, California Personal Injury Law Firm devoted to representing families of injured persons of automobile accidents. If you or someone you love, has been injured or killed in San Diego County, or Southern California, due to the negligence of another, please order your FREE copy of Mr. Blane's book, The 10 Secrets You Need To Know About Your Injury Case, BEFORE You Call A Lawyer. It is full of helpful information, insights, and secrets that will help you protect your legal rights. It normally sells for $16.95; however, it is free to all California residents, or those injured in a California accident.