RECENT COURT DECISIONS

Eugene Mason and Patrick Brown vs State Farm Mutual Insurance
In another of a long line of cases, the Utah district court rejected that an insurer, State Farm in this instance, violated the False Claims Act when it failed to reimburse the Medicare Trust Fund under MSP law after it originally contested coverage but later began to pay some claims.  The Court found that there was no evidence that State Farm's actions were knowing or willful, and could not meet the elements of a False Claims Act claim.  The plaintiffs did not assert a private right of action under the MSP statute.

Snook v. Oakland County Deputy Sheriffs
This case stands for the proposition that a settlement agreement will be enforced irrespective of whether the final Medicare Reimbursement Amount  is determined unless the parties clearly state otherwise.  In Snook v. Oakland County Deputy Sheriffs, et al., 2009 US Dist. LEXIS 75435 (U.S.D.MI, Southern Div., August 25, 2009), the plaintiff agreed to settle his assault and battery case for  $75,000 but only if the Medicare Reimbursement Amount did not exceed $10,000.  Read More

Vernon Hadden, Plantiff versus United States of America, Defendant
In this district court decision, and innocent pedestrian harmed in an automobile accident settled with the utility company that owned the truck involved in the accident.  The settlement also made the pedestrian responsible for payment of MSP liabilities.  When CMS demanded 100% of the MSP liability, which consumed most of the settlement, the pedestrian sought a reduction in the MSP payment based upon two arguments: comparative fault principles and the "made whole" doctrine. Read More

JACK WOODS, Plaintiff-Appellant, -v.- EMPIRE HEALTH CHOICE, INC., EMPIRE MEDICAL SERVICES, a division of EMPIRE HEALTH CHOICE ASSURANCE, INC.
Plaintiff-Appellant Jack Woods appeals from a judgment of the United States District Court for the Eastern District of New York (Irizarry, J.) dismissing for lack of standing his complaint asserting a cause of action under 42 U.S.C. § 1395y(b)(3)(A). Woods contends primarily that the District Court erred by determining that § 1395y(b)(3)(A) does not permit a private individual to assert a qui tam action on behalf of the Government. We conclude that 42 U.S.C. § 1395y(b)(3)(A) does not create a qui tam action, but rather merely enables a private party to bring an action to recover from a private insurer only where that private party has itself suffered an injury because a primary plan has failed to make a required payment to or on behalf of it.

Leggette v. B.V. Hedrick Gravel & Sand Company
In Leggette v. B.V. Hedrick Gravel & Sand Company, 2006 U.S. Dist. LEXIS 98297 (USDC North Carolina, 2006), plaintiffs commenced an action to recover health insurance benefits pursuant to the Employee Retirement Income Security Act (“ERISA”) and the Medicare Secondary Payer Act (“MSP”). Plaintiff, Willie Leggette, suffered from End-Stage Renal Disease (“ERSD”). Read More