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91_HB2166ccr001
LRB9102918JSpcccr3
1 91ST GENERAL ASSEMBLY
2 CONFERENCE COMMITTEE REPORT
3 ON HOUSE BILL 2166
4 -------------------------------------------------------------
5 -------------------------------------------------------------
6 To the President of the Senate and the Speaker of the
7 House of Representatives:
8 We, the conference committee appointed to consider the
9 differences between the houses in relation to Senate
10 Amendments No. 1 and No. 2 to House Bill 2166, recommend the
11 following:
12 (1) that the Senate recede from Senate Amendments No. 1
13 and No. 2; and
14 (2) that House Bill 2166 be amended by replacing the
15 title with the following:
16 "AN ACT to amend the Comprehensive Health Insurance Plan
17 Act by changing Sections 7 and 8 and repealing Section 8.5.";
18 and
19 by replacing everything after the enacting clause with the
20 following:
21 "Section 5. The Comprehensive Health Insurance Plan Act
22 is amended by changing Sections 7 and 8 as follows:
23 (215 ILCS 105/7) (from Ch. 73, par. 1307)
24 Sec. 7. Eligibility.
25 a. Except as provided in subsection (e) of this Section
26 or in Section 15 of this Act, any individual person who is
27 either a citizen of the United States or an alien lawfully
28 admitted for permanent residence and continues to be a
29 resident of this State shall be eligible for Plan coverage if
30 evidence is provided of:
31 (1) A notice of rejection or refusal to issue
32 substantially similar individual health insurance
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1 coverage for health reasons by a health insurance issuer;
2 or
3 (2) A refusal by a health insurance issuer to issue
4 individual health insurance coverage except at a rate
5 exceeding the applicable Plan rate for which the person
6 is responsible.
7 A rejection or refusal by a group health plan or health
8 insurance issuer offering only stop-loss or excess of loss
9 insurance or contracts, agreements, or other arrangements for
10 reinsurance coverage with respect to the applicant shall not
11 be sufficient evidence under this subsection.
12 b. The board shall promulgate a list of medical or
13 health conditions for which a person who is either a citizen
14 of the United States or an alien lawfully admitted for
15 permanent residence and a resident of this State would be
16 eligible for Plan coverage without applying for health
17 insurance coverage pursuant to subsection a. of this Section.
18 Persons who can demonstrate the existence or history of any
19 medical or health conditions on the list promulgated by the
20 board shall not be required to provide the evidence specified
21 in subsection a. of this Section. The list shall be
22 effective on the first day of the operation of the Plan and
23 may be amended from time to time as appropriate.
24 c. Family members of the same household who each are
25 covered persons are eligible for optional family coverage
26 under the Plan.
27 d. For persons qualifying for coverage in accordance
28 with Section 7 of this Act, the board shall, if it determines
29 that such appropriations as are made pursuant to Section 12
30 of this Act are insufficient to allow the board to accept all
31 of the eligible persons which it projects will apply for
32 enrollment under the Plan, limit or close enrollment to
33 ensure that the Plan is not over-subscribed and that it has
34 sufficient resources to meet its obligations to existing
35 enrollees. The board shall not limit or close enrollment for
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1 federally eligible individuals.
2 e. A person shall not be eligible for coverage under the
3 Plan if:
4 (1) He or she has or obtains other coverage under a
5 group health plan or health insurance coverage
6 substantially similar to or better than a Plan policy as
7 an insured or covered dependent or would be eligible to
8 have that coverage if he or she elected to obtain it.
9 Persons otherwise eligible for Plan coverage may,
10 however, solely for the purpose of having coverage for a
11 pre-existing condition, maintain other coverage only
12 while satisfying any pre-existing condition waiting
13 period under a Plan policy or a subsequent replacement
14 policy of a Plan policy.
15 (1.1) His or her prior coverage under a group
16 health plan or health insurance coverage, provided or
17 arranged by an employer of more than 10 employees was
18 discontinued for any reason without the entire group or
19 plan being discontinued and not replaced, provided he or
20 she remains an employee, or dependent thereof, of the
21 same employer.
22 (2) He or she is a recipient of or is approved to
23 receive medical assistance, except that a person may
24 continue to receive medical assistance through the
25 medical assistance no grant program, but only while
26 satisfying the requirements for a preexisting condition
27 under Section 8, subsection f. of this Act. Payment of
28 premiums pursuant to this Act shall be allocable to the
29 person's spenddown for purposes of the medical assistance
30 no grant program, but that person shall not be eligible
31 for any Plan benefits while that person remains eligible
32 for medical assistance. If the person continues to
33 receive or be approved to receive medical assistance
34 through the medical assistance no grant program at or
35 after the time that requirements for a preexisting
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1 condition are satisfied, the person shall not be eligible
2 for coverage under the Plan. In that circumstance,
3 coverage under the plan shall terminate as of the
4 expiration of the preexisting condition limitation
5 period. Under all other circumstances, coverage under
6 the Plan shall automatically terminate as of the
7 effective date of any medical assistance.
8 (3) Except as provided in Section 15, the person
9 has previously participated in the Plan and voluntarily
10 terminated Plan coverage, unless 12 months have elapsed
11 since the person's latest voluntary termination of
12 coverage.
13 (4) The person fails to pay the required premium
14 under the covered person's terms of enrollment and
15 participation, in which event the liability of the Plan
16 shall be limited to benefits incurred under the Plan for
17 the time period for which premiums had been paid and the
18 covered person remained eligible for Plan coverage.
19 (5) The Plan has paid a total of $1,000,000 in
20 benefits on behalf of the covered person.
21 (6) The person is a resident of a public
22 institution.
23 (7) The person's premium is paid for or reimbursed
24 under any government sponsored program or by any
25 government agency or health care provider, except as an
26 otherwise qualifying full-time employee, or dependent of
27 such employee, of a government agency or health care
28 provider.
29 (8) The person has or later receives other benefits
30 or funds from any settlement, judgement, or award
31 resulting from any accident or injury, regardless of the
32 date of the accident or injury, or any other
33 circumstances creating a legal liability for damages due
34 that person by a third party, whether the settlement,
35 judgment, or award is in the form of a contract,
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1 agreement, or trust on behalf of a minor or otherwise and
2 whether the settlement, judgment, or award is payable to
3 the person, his or her dependent, estate, personal
4 representative, or guardian in a lump sum or over time,
5 so long as there continues to be benefits or assets
6 remaining from those sources in an amount in excess of
7 $100,000.
8 (9) Within the 5 years prior to the date a person's
9 Plan application is received by the Board, the person's
10 coverage under any health care benefit program as defined
11 in 18 U.S.C. 24, including any public or private plan or
12 contract under which any medical benefit, item, or
13 service is provided, was terminated as a result of any
14 act or practice that constitutes fraud under State or
15 federal law or as a result of an intentional
16 misrepresentation of material fact; or if that person
17 knowingly and willfully obtained or attempted to obtain,
18 or fraudulently aided or attempted to aid any other
19 person in obtaining, any coverage or benefits under the
20 Plan to which that person was not entitled.
21 f. The board or the administrator shall require
22 verification of residency and may require any additional
23 information or documentation, or statements under oath, when
24 necessary to determine residency upon initial application and
25 for the entire term of the policy.
26 g. Coverage shall cease (i) on the date a person is no
27 longer a resident of Illinois, (ii) on the date a person
28 requests coverage to end, (iii) upon the death of the covered
29 person, (iv) on the date State law requires cancellation of
30 the policy, or (v) at the Plan's option, 30 days after the
31 Plan makes any inquiry concerning a person's eligibility or
32 place of residence to which the person does not reply.
33 h. Except under the conditions set forth in subsection g
34 of this Section, the coverage of any person who ceases to
35 meet the eligibility requirements of this Section shall be
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1 terminated at the end of the current policy period for which
2 the necessary premiums have been paid.
3 (Source: P.A. 89-486, eff. 6-21-96; 90-30, eff. 7-1-97.)
4 (215 ILCS 105/8) (from Ch. 73, par. 1308)
5 Sec. 8. Minimum benefits.
6 a. Availability. The Plan shall offer in an annually
7 renewable policy major medical expense coverage to every
8 eligible person who is not eligible for Medicare. Major
9 medical expense coverage offered by the Plan shall pay an
10 eligible person's covered expenses, subject to limit on the
11 deductible and coinsurance payments authorized under
12 paragraph (4) of subsection d of this Section, up to a
13 lifetime benefit limit of $1,000,000 per covered individual.
14 The maximum limit under this subsection shall not be altered
15 by the Board, and no actuarial equivalent benefit may be
16 substituted by the Board. Any person who otherwise would
17 qualify for coverage under the Plan, but is excluded because
18 he or she is eligible for Medicare, shall be eligible for any
19 separate Medicare supplement policy or policies which the
20 Board may offer.
21 b. Outline of benefits. Covered expenses shall be
22 limited to the usual and customary charge, including
23 negotiated fees, in the locality for the following services
24 and articles when prescribed by a physician and determined by
25 the Plan to be medically necessary for the following areas of
26 services, subject to such separate deductibles, co-payments,
27 exclusions, and other limitations on benefits as the Board
28 shall establish and approve, and the other provisions of this
29 Section:
30 (1) Hospital services, except that any services
31 provided by a hospital that is located more than 75 miles
32 outside the State of Illinois shall be covered only for a
33 maximum of 45 days in any calendar year. With respect to
34 covered expenses incurred during any calendar year ending
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1 on or after December 31, 1999, inpatient hospitalization
2 of an eligible person for the treatment of mental illness
3 at a hospital located within the State of Illinois shall
4 be subject to the same terms and conditions as for any
5 other illness.
6 (2) Professional services for the diagnosis or
7 treatment of injuries, illnesses or conditions, other
8 than dental and mental and nervous disorders as described
9 in paragraph (17), which are rendered by a physician, or
10 by other licensed professionals at the physician's
11 direction.
12 (2.5) Professional services provided by a physician
13 to children under the age of 16 years for physical
14 examinations and age appropriate immunizations ordered by
15 a physician licensed to practice medicine in all its
16 branches.
17 (3) (Blank).
18 (4) Outpatient prescription drugs that by law
19 require requiring a physician's prescription written by a
20 physician licensed to practice medicine in all its
21 branches subject to such separate deductible, copayment,
22 and other limitations or restrictions as the Board shall
23 approve, including the use of a prescription drug card or
24 any other program, or both.
25 (5) Skilled nursing services of a licensed skilled
26 nursing facility for not more than 120 days during a
27 policy year.
28 (6) Services of a home health agency in accord with
29 a home health care plan, up to a maximum of 270 visits
30 per year.
31 (7) Services of a licensed hospice for not more
32 than 180 days during a policy year.
33 (8) Use of radium or other radioactive materials.
34 (9) Oxygen.
35 (10) Anesthetics.
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1 (11) Orthoses and prostheses other than dental.
2 (12) Rental or purchase in accordance with Board
3 policies or procedures of durable medical equipment,
4 other than eyeglasses or hearing aids, for which there is
5 no personal use in the absence of the condition for which
6 it is prescribed.
7 (13) Diagnostic x-rays and laboratory tests.
8 (14) Oral surgery for excision of partially or
9 completely unerupted impacted teeth or the gums and
10 tissues of the mouth, when not performed in connection
11 with the routine extraction or repair of teeth, that is
12 required to treat and oral surgery and procedures,
13 including orthodontics and prosthetics necessary for
14 craniofacial or maxillofacial conditions and to correct
15 congenital defects or injuries to natural teeth or a
16 fractured jaw due to an accident that occurred while a
17 covered person.
18 (15) Physical, speech, and functional occupational
19 therapy as medically necessary and provided by
20 appropriate licensed professionals.
21 (16) Emergency and other medically necessary
22 transportation provided by a licensed ambulance service
23 to the nearest health care facility qualified to treat a
24 covered illness, injury, or condition, subject to the
25 provisions of the Emergency Medical Systems (EMS) Act.
26 (17) Outpatient services for diagnosis and
27 treatment of mental and nervous disorders provided that a
28 covered person shall be required to make a copayment not
29 to exceed 50% and that the Plan's payment shall not
30 exceed such amounts as are established by the Board.
31 (18) Human organ or tissue transplants specified by
32 the Board that are performed at a hospital designated by
33 the Board as a participating transplant center for that
34 specific organ or tissue transplant.
35 (19) Naprapathic services, as appropriate, provided
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1 by a licensed naprapathic practitioner.
2 c. Exclusions. Covered expenses of the Plan shall not
3 include the following:
4 (1) Any charge for treatment for cosmetic purposes
5 other than for reconstructive surgery when the service is
6 incidental to or follows surgery resulting from injury,
7 sickness or other diseases of the involved part or
8 surgery for the repair or treatment of a congenital
9 bodily defect to restore normal bodily functions.
10 (2) Any charge for care that is primarily for rest,
11 custodial, educational, or domiciliary purposes.
12 (3) Any charge for services in a private room to
13 the extent it is in excess of the institution's charge
14 for its most common semiprivate room, unless a private
15 room is prescribed as medically necessary by a physician.
16 (4) That part of any charge for room and board or
17 for services rendered or articles prescribed by a
18 physician, dentist, or other health care personnel that
19 exceeds the reasonable and customary charge in the
20 locality or for any services or supplies not medically
21 necessary for the diagnosed injury or illness.
22 (5) Any charge for services or articles the
23 provision of which is not within the scope of licensure
24 of the institution or individual providing the services
25 or articles.
26 (6) Any expense incurred prior to the effective
27 date of coverage by the Plan for the person on whose
28 behalf the expense is incurred.
29 (7) Dental care, dental surgery, dental treatment
30 or dental appliances, except as provided in paragraph
31 (14) of subsection b of this Section.
32 (8) Eyeglasses, contact lenses, hearing aids or
33 their fitting.
34 (9) Illness or injury due to acts of war.
35 (10) Services of blood donors and any fee for
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1 failure to replace the first 3 pints of blood provided to
2 a covered person each policy year.
3 (11) Personal supplies or services provided by a
4 hospital or nursing home, or any other nonmedical or
5 nonprescribed supply or service.
6 (12) Routine maternity charges for a pregnancy,
7 except where added as optional coverage with payment of
8 an additional premium for pregnancy resulting from
9 conception occurring after the effective date of the
10 optional coverage.
11 (13) (Blank).
12 (14) Any expense or charge for services, drugs, or
13 supplies that are: (i) not provided in accord with
14 generally accepted standards of current medical practice;
15 (ii) for procedures, treatments, equipment, transplants,
16 or implants, any of which are investigational,
17 experimental, or for research purposes; (iii)
18 investigative and not proven safe and effective; or (iv)
19 for, or resulting from, a gender transformation
20 operation.
21 (15) Any expense or charge for routine physical
22 examinations or tests except as provided in item (2.5) of
23 subsection b of this Section.
24 (16) Any expense for which a charge is not made in
25 the absence of insurance or for which there is no legal
26 obligation on the part of the patient to pay.
27 (17) Any expense incurred for benefits provided
28 under the laws of the United States and this State,
29 including Medicare, and Medicaid, and other medical
30 assistance, maternal and child health services and any
31 other program that is administered or funded by the
32 Department of Human Services, Department of Public Aid,
33 or Department of Public Health, military
34 service-connected disability payments, medical services
35 provided for members of the armed forces and their
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1 dependents or employees of the armed forces of the United
2 States, and medical services financed on behalf of all
3 citizens by the United States.
4 (18) Any expense or charge for in vitro
5 fertilization, artificial insemination, or any other
6 artificial means used to cause pregnancy.
7 (19) Any expense or charge for oral contraceptives
8 used for birth control or any other temporary birth
9 control measures.
10 (20) Any expense or charge for sterilization or
11 sterilization reversals.
12 (21) Any expense or charge for weight loss
13 programs, exercise equipment, or treatment of obesity,
14 except when certified by a physician as morbid obesity
15 (at least 2 times normal body weight).
16 (22) Any expense or charge for acupuncture
17 treatment unless used as an anesthetic agent for a
18 covered surgery.
19 (23) Any expense or charge for or related to organ
20 or tissue transplants other than those performed at a
21 hospital with a Board approved organ transplant program
22 that has been designated by the Board as a preferred or
23 exclusive provider organization for that specific organ
24 or tissue transplant.
25 (24) Any expense or charge for procedures,
26 treatments, equipment, or services that are provided in
27 special settings for research purposes or in a controlled
28 environment, are being studied for safety, efficiency,
29 and effectiveness, and are awaiting endorsement by the
30 appropriate national medical speciality college for
31 general use within the medical community.
32 d. Deductibles and coinsurance.
33 The Plan coverage defined in Section 6 shall provide for
34 a choice of deductibles per individual as authorized by the
35 Board. If 2 individual members of the same family household,
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1 who are both covered persons under the Plan, satisfy the same
2 applicable deductibles, no other member of that family who is
3 also a covered person under the Plan shall be required to
4 meet any deductibles for the balance of that calendar year.
5 The deductibles must be applied first to the authorized
6 amount of covered expenses incurred by the covered person. A
7 mandatory coinsurance requirement shall be imposed at the
8 rate authorized by the Board in excess of the mandatory
9 deductible, the coinsurance in the aggregate not to exceed
10 such amounts as are authorized by the Board per annum. At
11 its discretion the Board may, however, offer catastrophic
12 coverages or other policies that provide for larger
13 deductibles with or without coinsurance requirements. The
14 deductibles and coinsurance factors may be adjusted annually
15 according to the Medical Component of the Consumer Price
16 Index.
17 e. Scope of coverage.
18 (1) In approving any of the benefit plans to be offered
19 by the Plan, the Board shall establish such benefit levels,
20 deductibles, coinsurance factors, exclusions, and limitations
21 as it may deem appropriate and that it believes to be
22 generally reflective of and commensurate with health
23 insurance coverage that is provided in the individual market
24 in this State.
25 (2) The benefit plans approved by the Board may also
26 provide for and employ various cost containment measures and
27 other requirements including, but not limited to,
28 preadmission certification, prior approval, second surgical
29 opinions, concurrent utilization review programs, individual
30 case management, preferred provider organizations, health
31 maintenance organizations, and other cost effective
32 arrangements for paying for covered expenses.
33 f. Preexisting conditions.
34 (1) Except for federally eligible individuals
35 qualifying for Plan coverage under Section 15 of this Act
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1 or eligible persons who qualify for and elect to purchase
2 the waiver authorized in paragraph (3) of this subsection
3 Waiver: The preexisting condition
15 exclusions as set forth in paragraph (1) of this
16 subsection shall be waived to the extent to which the
17 eligible person: (a) has satisfied similar exclusions
18 under any prior health insurance coverage or group health
19 plan that was involuntarily terminated; (b) is ineligible
20 for any continuation coverage that would continue or
21 provide substantially similar coverage following that
22 termination; and (c) has applied for Plan coverage not
23 later than 30 days following the involuntary termination.
24 No policy or plan shall be deemed to have been
25 involuntarily terminated if the master policyholder or
26 other controlling party elected to change insurance
27 coverage from one health insurance issuer or group health
28 plan to another even if that decision resulted in a
29 discontinuation of coverage for any individual under the
30 plan, either totally or for any medical condition. For
31 each eligible person who qualifies for and elects this
32 waiver, there shall be added to each payment of premium,
33 on a prorated basis, a surcharge of up to 10% of the
34 otherwise applicable annual premium for as long as that
35 individual's coverage under the Plan remains in effect or
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1 60 months, whichever is less.
2 g. Other sources primary; nonduplication of benefits.
3 (1) The Plan shall be the last payor of benefits
4 whenever any other benefit or source of third party
5 payment is available. Subject to the provisions of
6 subsection e of Section 7, benefits otherwise payable
7 under Plan coverage shall be reduced by all amounts paid
8 or payable by Medicare or any other government program or
9 through any health insurance or group health plan,
10 whether by insurance, reimbursement, or otherwise, or
11 through any third party liability, settlement, judgment,
12 or award, regardless of the date of the settlement,
13 judgment, or award, whether the settlement, judgment, or
14 award is in the form of a contract, agreement, or trust
15 on behalf of a minor or otherwise and whether the
16 settlement, judgment, or award is payable to the covered
17 person, his or her dependent, estate, personal
18 representative, or guardian in a lump sum or over time,
19 and by all hospital or medical expense benefits paid or
20 payable under any worker's compensation coverage,
21 automobile medical payment, or liability insurance,
22 whether provided on the basis of fault or nonfault, and
23 by any hospital or medical benefits paid or payable under
24 or provided pursuant to any State or federal law or
25 program.
26 (2) The Plan shall have a cause of action against
27 any covered person or any other person or entity for the
28 recovery of any amount paid to the extent the amount was
29 for treatment, services, or supplies not covered in this
30 Section or in excess of benefits as set forth in this
31 Section.
32 (3) Whenever benefits are due from the Plan because
33 of sickness or an injury to a covered person resulting
34 from a third party's wrongful act or negligence and the
35 covered person has recovered or may recover damages from
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1 a third party or its insurer, the Plan shall have the
2 right to reduce benefits or to refuse to pay benefits
3 that otherwise may be payable by the amount of damages
4 that the covered person has recovered or may recover
5 regardless of the date of the sickness or injury or the
6 date of any settlement, judgment, or award resulting from
7 that sickness or injury.
8 During the pendency of any action or claim that is
9 brought by or on behalf of a covered person against a
10 third party or its insurer, any benefits that would
11 otherwise be payable except for the provisions of this
12 paragraph (3) shall be paid if payment by or for the
13 third party has not yet been made and the covered person
14 or, if incapable, that person's legal representative
15 agrees in writing to pay back promptly the benefits paid
16 as a result of the sickness or injury to the extent of
17 any future payments made by or for the third party for
18 the sickness or injury. This agreement is to apply
19 whether or not liability for the payments is established
20 or admitted by the third party or whether those payments
21 are itemized.
22 Any amounts due the plan to repay benefits may be
23 deducted from other benefits payable by the Plan after
24 payments by or for the third party are made.
25 (4) Benefits due from the Plan may be reduced or
26 refused as an offset against any amount otherwise
27 recoverable under this Section.
28 h. Right of subrogation; recoveries.
29 (1) Whenever the Plan has paid benefits because of
30 sickness or an injury to any covered person resulting
31 from a third party's wrongful act or negligence, or for
32 which an insurer is liable in accordance with the
33 provisions of any policy of insurance, and the covered
34 person has recovered or may recover damages from a third
35 party that is liable for the damages, the Plan shall have
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1 the right to recover the benefits it paid from any
2 amounts that the covered person has received or may
3 receive regardless of the date of the sickness or injury
4 or the date of any settlement, judgment, or award
5 resulting from that sickness or injury. The Plan shall
6 be subrogated to any right of recovery the covered person
7 may have under the terms of any private or public health
8 care coverage or liability coverage, including coverage
9 under the Workers' Compensation Act or the Workers'
10 Occupational Diseases Act, without the necessity of
11 assignment of claim or other authorization to secure the
12 right of recovery. To enforce its subrogation right, the
13 Plan may (i) intervene or join in an action or proceeding
14 brought by the covered person or his personal
15 representative, including his guardian, conservator,
16 estate, dependents, or survivors, against any third party
17 or the third party's insurer that may be liable or (ii)
18 institute and prosecute legal proceedings against any
19 third party or the third party's insurer that may be
20 liable for the sickness or injury in an appropriate court
21 either in the name of the Plan or in the name of the
22 covered person or his personal representative, including
23 his guardian, conservator, estate, dependents, or
24 survivors.
25 (2) If any action or claim is brought by or on
26 behalf of a covered person against a third party or the
27 third party's insurer, the covered person or his personal
28 representative, including his guardian, conservator,
29 estate, dependents, or survivors, shall notify the Plan
30 by personal service or registered mail of the action or
31 claim and of the name of the court in which the action or
32 claim is brought, filing proof thereof in the action or
33 claim. The Plan may, at any time thereafter, join in the
34 action or claim upon its motion so that all orders of
35 court after hearing and judgment shall be made for its
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1 protection. No release or settlement of a claim for
2 damages and no satisfaction of judgment in the action
3 shall be valid without the written consent of the Plan to
4 the extent of its interest in the settlement or judgment
5 and of the covered person or his personal representative.
6 (3) In the event that the covered person or his
7 personal representative fails to institute a proceeding
8 against any appropriate third party before the fifth
9 month before the action would be barred, the Plan may, in
10 its own name or in the name of the covered person or
11 personal representative, commence a proceeding against
12 any appropriate third party for the recovery of damages
13 on account of any sickness, injury, or death to the
14 covered person. The covered person shall cooperate in
15 doing what is reasonably necessary to assist the Plan in
16 any recovery and shall not take any action that would
17 prejudice the Plan's right to recovery. The Plan shall
18 pay to the covered person or his personal representative
19 all sums collected from any third party by judgment or
20 otherwise in excess of amounts paid in benefits under the
21 Plan and amounts paid or to be paid as costs, attorneys
22 fees, and reasonable expenses incurred by the Plan in
23 making the collection or enforcing the judgment.
24 (4) In the event that a covered person or his
25 personal representative, including his guardian,
26 conservator, estate, dependents, or survivors, recovers
27 damages from a third party for sickness or injury caused
28 to the covered person, the covered person or the personal
29 representative shall pay to the Plan from the damages
30 recovered the amount of benefits paid or to be paid on
31 behalf of the covered person.
32 (5) When the action or claim is brought by the
33 covered person alone and the covered person incurs a
34 personal liability to pay attorney's fees and costs of
35 litigation, the Plan's claim for reimbursement of the
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1 benefits provided to the covered person shall be the full
2 amount of benefits paid to or on behalf of the covered
3 person under this Act less a pro rata share that
4 represents the Plan's reasonable share of attorney's fees
5 paid by the covered person and that portion of the cost
6 of litigation expenses determined by multiplying by the
7 ratio of the full amount of the expenditures to the full
8 amount of the judgement, award, or settlement.
9 (6) In the event of judgment or award in a suit or
10 claim against a third party or insurer, the court shall
11 first order paid from any judgement or award the
12 reasonable litigation expenses incurred in preparation
13 and prosecution of the action or claim, together with
14 reasonable attorney's fees. After payment of those
15 expenses and attorney's fees, the court shall apply out
16 of the balance of the judgment or award an amount
17 sufficient to reimburse the Plan the full amount of
18 benefits paid on behalf of the covered person under this
19 Act, provided the court may reduce and apportion the
20 Plan's portion of the judgement proportionate to the
21 recovery of the covered person. The burden of producing
22 evidence sufficient to support the exercise by the court
23 of its discretion to reduce the amount of a proven charge
24 sought to be enforced against the recovery shall rest
25 with the party seeking the reduction. The court may
26 consider the nature and extent of the injury, economic
27 and non-economic loss, settlement offers, comparative
28 negligence as it applies to the case at hand, hospital
29 costs, physician costs, and all other appropriate costs.
30 The Plan shall pay its pro rata share of the attorney
31 fees based on the Plan's recovery as it compares to the
32 total judgment. Any reimbursement rights of the Plan
33 shall take priority over all other liens and charges
34 existing under the laws of this State with the exception
35 of any attorney liens filed under the Attorneys Lien Act.
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1 (7) The Plan may compromise or settle and release
2 any claim for benefits provided under this Act or waive
3 any claims for benefits, in whole or in part, for the
4 convenience of the Plan or if the Plan determines that
5 collection would result in undue hardship upon the
6 covered person.
7 (Source: P.A. 89-486, eff. 6-21-96; 90-7, eff. 6-10-97;
8 90-30, eff. 7-1-97; 90-655, eff. 7-30-98.)
9 (215 ILCS 105/8.5 rep.)
10 Section 10. The Comprehensive Health Insurance Plan Act
11 is amended by repealing Section 8.5.
12 Section 99. Effective date. This Act takes effect upon
13 becoming law.".
14 Submitted on May 26, 1999
15 s/Sen. Robert Madigan s/Rep. Frank Mautino
16 s/Sen. Thomas Walsh s/Rep. Barbara Flynn Currie
17 s/Sen. Doris Karpiel s/Rep. Kurt Granberg
18 s/Sen. Denny Jacobs s/Rep. Art Tenhouse
19 s/Sen. Robert Molaro s/Rep. Tom Cross
20 Committee for the Senate Committee for the House
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