Employers grab accident victims' cash

By The Wall Street Journal

A collision with a tractor-trailer seven years ago left 52-year-old Deborah Shank permanently brain-damaged and in a wheelchair. Her husband, Jim, and three sons found a small source of solace: a $700,000 accident settlement from the trucking company involved.

After legal fees and other expenses, the remaining $417,000 was put in a special trust. It was to be used for Deborah Shank's care.

Instead, all of it is now slated to go to Deborah's former employer, Wal-Mart Stores.

Two years ago, the retail giant's health plan sued the Shanks for the $470,000 it had spent on her medical care. A federal judge ruled last year in Wal-Mart's favor, backed by an appeals-court decision in August. Now, Deborah's family has to rely on Medicaid and her Social Security payments to keep up her round-the-clock care.

"I don't understand why they need to do this," says Jim Shank on a recent visit to the nursing home, between shifts as a maintenance worker and running a tanning salon. "This girl needs the money more than they do."

Deborah, who needs help with eating and other basic tasks, has spent more time alone since Jim had to let her private caregiver go. At some point, he says, she may have to be moved from a private to a semiprivate room in the nursing home where she lives.

The reason is a clause in Wal-Mart's health plan that Deborah Shank didn't notice when she started stocking shelves at a nearby store eight years ago. Like most company health plans, Wal-Mart's reserves the right to recoup the medical expenses it paid for someone's treatment if the person also collects damages in an injury suit.

Going after the money

Until recently, many employers didn't vigilantly enforce the provision, and some states and federal courts didn't think the claim held water. But as the cost of covering workers continues to escalate, employers and health plans are getting more aggressive about going after the money. A U.S. Supreme Court ruling last year also has given them a clearer legal map to suing employees and winning.

In insurance circles, the recovery practice is called "subrogation." Employers and insurers say it's necessary to ensure that medical expenses aren't paid twice. By recovering those costs from someone who's been compensated elsewhere, they argue, they're saving money for everyone on the plan.

Sharon Weber, a spokeswoman for Wal-Mart, declined to discuss the details of the Shanks' case, but she said the company was obliged to act in the interest of the health benefits of its employees as a whole. "While the case involves a tragic situation, our responsibility is to follow the provisions of the (company health) plan which governs the health benefits of our associates," she said.

"Employers are trying to make sure these plans run as efficiently as possible," says Jay Kirschbaum, a senior vice president at global insurance broker Willis Group Holdings. "They also have a fiduciary duty to the plan and the entire group of employees that are covered by it."

The recovery practice

Already, the recovery practice is one of the variables that plaintiffs lawyers are considering as they decide whether it's in their clients' interests to participate in the $5 billion offered by Merck to settle lawsuits over its painkiller Vioxx.

Health plans recovered sizable amounts for medical expenses from other big product-liability settlements, such as for the "fen-phen" diet-drug combination and Sulzer Orthopedics' hip implants. Many insurers and the employer plans they administer are expected to pursue a piece of the Vioxx settlement.

In cases such as the Shanks', in which injuries and medical costs are catastrophic, accident victims sometimes can be left with little or none of the money they fought for in court. Health plans increasingly are adopting language such as Wal-Mart's, which dictates that it is to be paid first out of any settlement, regardless of what remains for the injured person. Moreover, the victim is responsible for all legal costs in pursuing the suit.

"It's especially in the catastrophic cases that people are almost never fully compensated," says Roger Baron, a professor of law at the University of South Dakota and a specialist in health-plan law. "And then their health plan, that's been collecting premiums from them all this time, wants to take it away?"

Tempting savings

Such recoveries represent a tempting savings for insurers, employers and union-administered plans. The American Benefits Council and America's Health Insurance Plans, a health-insurer lobby, estimate health plans recoup about $1 billion a year in medical claims from accident settlements and other third parties. A cottage industry of auditing firms, benefit-recovery specialists and subrogation lawyers help them. They estimate that 1% to 3% of health-care spending is potentially recoverable from such claims.

"In the past, employers used to think of this as an afterthought," says Tom Lawrence, the chief executive of Benefit Recovery, a Memphis, Tenn., company whose clients include Southwest Airlines and hospital chain HCA.

HCA says it saw annual savings from recouped claims rise to $1.8 million in 2006 from about $800,000 in 2000 after hiring the firm.

Benefit Recovery contracts directly with employers. It says it's able to recover $12 to $15 per health-plan member a year -- up to $1.5 million for a big plan with 100,000 members -- by recovering medical expenses from injury-suit settlements.

Refusing to pay

Until recently, employers and insurers generally didn't go after small claims. But more-sophisticated claims tracking has made it easier. Recovery companies systematically search claims for certain medical codes -- say, a sprained ankle or head trauma -- that flag a potential accident. Claims examiners then mail a questionnaire and often follow up with calls. If the injured person confirms it was an accident, the firm tracks whether the patient files an injury suit.

If there is a lawsuit settlement, employers may seek to recoup money they paid for medical expenses. In many cases, it's relatively cut and dried: Often medical expenses are just a portion of the overall damages award, or the accident victim's attorney may reach a compromise with the health plan ahead of any settlement.

Continued: Reimbursement agreements

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