| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
1 | AN ACT concerning insurance.
| ||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||
4 | Section 5. The Comprehensive Health Insurance Plan Act is | ||||||||||||||||||||||||
5 | amended by changing Section 8 as follows: | ||||||||||||||||||||||||
6 | (215 ILCS 105/8) (from Ch. 73, par. 1308) | ||||||||||||||||||||||||
7 | Sec. 8. Minimum benefits. | ||||||||||||||||||||||||
8 | a. Availability. The Plan shall offer in a periodically | ||||||||||||||||||||||||
9 | renewable policy major medical expense coverage to every | ||||||||||||||||||||||||
10 | eligible
person who is not eligible for Medicare. Major medical
| ||||||||||||||||||||||||
11 | expense coverage offered by the Plan shall pay an eligible | ||||||||||||||||||||||||
12 | person's
covered expenses, subject to limit on the deductible | ||||||||||||||||||||||||
13 | and coinsurance
payments authorized under paragraph (4) of | ||||||||||||||||||||||||
14 | subsection d of this Section,
up to a lifetime benefit limit of | ||||||||||||||||||||||||
15 | $5,000,000. The maximum
limit under this subsection shall not | ||||||||||||||||||||||||
16 | be altered by the Board, and no
actuarial equivalent benefit | ||||||||||||||||||||||||
17 | may be substituted by the Board.
Any person who otherwise would | ||||||||||||||||||||||||
18 | qualify for coverage under the Plan, but
is excluded because he | ||||||||||||||||||||||||
19 | or she is eligible for Medicare, shall be eligible
for any | ||||||||||||||||||||||||
20 | separate Medicare supplement policy or policies which the Board | ||||||||||||||||||||||||
21 | may
offer. | ||||||||||||||||||||||||
22 | b. Outline of benefits. Covered expenses shall be
limited | ||||||||||||||||||||||||
23 | to the usual and customary charge, including negotiated fees, |
| |||||||
| |||||||
1 | in
the locality for the following services and articles when | ||||||
2 | prescribed by a
physician and determined by the Plan to be | ||||||
3 | medically necessary
for the following areas of services, | ||||||
4 | subject to such separate deductibles,
co-payments, exclusions, | ||||||
5 | and other limitations on benefits as the Board shall
establish | ||||||
6 | and approve, and the other provisions of this Section: | ||||||
7 | (1) Hospital
services, except that
any services | ||||||
8 | provided by a hospital that is
located more than 75 miles | ||||||
9 | outside the State of Illinois shall be covered only
for a | ||||||
10 | maximum of 45 days in any calendar year. With respect to | ||||||
11 | covered
expenses incurred during any calendar year ending | ||||||
12 | on or after December 31,
1999, inpatient hospitalization of | ||||||
13 | an eligible person for the
treatment of mental illness at a | ||||||
14 | hospital located within the State of
Illinois
shall be | ||||||
15 | subject to the same terms and conditions as for any other | ||||||
16 | illness. | ||||||
17 | (2) Professional services for the diagnosis or | ||||||
18 | treatment of injuries,
illnesses or conditions, other than | ||||||
19 | dental and mental
and
nervous disorders as
described in | ||||||
20 | paragraph (17), which are rendered by a physician, or by | ||||||
21 | other
licensed professionals at the physician's
direction. | ||||||
22 | This includes reconstruction of the breast on which a | ||||||
23 | mastectomy
was performed; surgery and reconstruction of | ||||||
24 | the other breast to produce a
symmetrical appearance; and | ||||||
25 | prostheses and treatment of physical complications
at all | ||||||
26 | stages of the mastectomy, including lymphedemas. |
| |||||||
| |||||||
1 | (2.5) Professional services provided by a physician to | ||||||
2 | children under
the age of 16 years for physical | ||||||
3 | examinations and age appropriate
immunizations ordered by | ||||||
4 | a physician licensed to practice medicine in all its
| ||||||
5 | branches. | ||||||
6 | (3) (Blank). | ||||||
7 | (4) Outpatient prescription drugs that by law require
a
| ||||||
8 | prescription
written by a physician licensed to practice | ||||||
9 | medicine in all its branches
subject to such separate | ||||||
10 | deductible, copayment, and other limitations or
| ||||||
11 | restrictions as the Board shall approve, including the use | ||||||
12 | of a prescription
drug card or any other program, or both. | ||||||
13 | (5) Skilled nursing services of a licensed
skilled
| ||||||
14 | nursing facility for not more than 120 days during a policy | ||||||
15 | year. | ||||||
16 | (6) Services of a home health agency in accord with a | ||||||
17 | home health care
plan, up to a maximum of 270 visits per | ||||||
18 | year. | ||||||
19 | (7) Services of a licensed hospice for not more than | ||||||
20 | 180
days during a policy year. | ||||||
21 | (8) Use of radium or other radioactive materials. | ||||||
22 | (9) Oxygen. | ||||||
23 | (10) Anesthetics. | ||||||
24 | (11) Orthoses and prostheses other than dental. | ||||||
25 | (12) Rental or purchase in accordance with Board | ||||||
26 | policies or
procedures of durable medical equipment, other |
| |||||||
| |||||||
1 | than eyeglasses or hearing
aids, for which there is no | ||||||
2 | personal use in the absence of the condition
for which it | ||||||
3 | is prescribed. | ||||||
4 | (13) Diagnostic x-rays and laboratory tests. | ||||||
5 | (14) Oral surgery (i) for excision of partially or | ||||||
6 | completely unerupted
impacted teeth when not performed in
| ||||||
7 | connection with the routine extraction or repair of teeth; | ||||||
8 | (ii) for excision
of tumors or cysts of the jaws, cheeks, | ||||||
9 | lips, tongue, and roof and floor of the
mouth; (iii) | ||||||
10 | required for correction of cleft lip and palate
and
other | ||||||
11 | craniofacial and maxillofacial birth defects; or (iv) for | ||||||
12 | treatment of injuries to natural teeth or a fractured jaw | ||||||
13 | due to an accident. | ||||||
14 | (15) Physical, speech, and functional occupational | ||||||
15 | therapy as
medically necessary and provided by appropriate | ||||||
16 | licensed professionals. | ||||||
17 | (16) Emergency and other medically necessary | ||||||
18 | transportation provided
by a licensed ambulance service to | ||||||
19 | the
nearest health care facility qualified to treat a | ||||||
20 | covered
illness, injury, or condition, subject to the | ||||||
21 | provisions of the
Emergency Medical Systems (EMS) Act. | ||||||
22 | (17) Outpatient services for
diagnosis and
treatment | ||||||
23 | of mental and nervous disorders provided that a
covered | ||||||
24 | person shall be required to make a copayment not to exceed | ||||||
25 | 50% and that
the Plan's payment shall not exceed such | ||||||
26 | amounts as are established by the
Board. |
| |||||||
| |||||||
1 | (18) Human organ or tissue transplants specified by the | ||||||
2 | Board that
are performed at a hospital designated by the | ||||||
3 | Board as a participating
transplant center for that | ||||||
4 | specific organ or tissue transplant. | ||||||
5 | (19) Naprapathic services, as appropriate, provided by | ||||||
6 | a licensed
naprapathic practitioner. | ||||||
7 | c. Exclusions. Covered expenses of the Plan shall not
| ||||||
8 | include the following: | ||||||
9 | (1) Any charge for treatment for cosmetic purposes | ||||||
10 | other than for
reconstructive surgery when the service is | ||||||
11 | incidental to or follows
surgery resulting from injury, | ||||||
12 | sickness or other diseases of the involved
part or surgery | ||||||
13 | for the repair or treatment of a congenital bodily defect
| ||||||
14 | to restore normal bodily functions. | ||||||
15 | (2) Any charge for care that is primarily for rest,
| ||||||
16 | custodial, educational, or domiciliary purposes. | ||||||
17 | (3) Any charge for services in a private room to the | ||||||
18 | extent it is in
excess of the institution's charge for its | ||||||
19 | most common semiprivate room,
unless a private room is | ||||||
20 | prescribed as medically necessary by a physician. | ||||||
21 | (4) That part of any charge for room and board or for | ||||||
22 | services
rendered or articles prescribed by a physician, | ||||||
23 | dentist, or other health
care personnel that exceeds the | ||||||
24 | reasonable and customary charge in the
locality or for any | ||||||
25 | services or supplies not medically necessary for the
| ||||||
26 | diagnosed injury or illness. |
| |||||||
| |||||||
1 | (5) Any charge for services or articles the provision | ||||||
2 | of which is not
within the scope of licensure of the | ||||||
3 | institution or individual
providing the services or | ||||||
4 | articles. | ||||||
5 | (6) Any expense incurred prior to the effective date of | ||||||
6 | coverage by the
Plan for the person on whose behalf the | ||||||
7 | expense is incurred. | ||||||
8 | (7) Dental care, dental surgery, dental treatment, any | ||||||
9 | other dental
procedure involving the teeth or | ||||||
10 | periodontium, or any dental appliances,
including crowns, | ||||||
11 | bridges, implants, or partial or complete dentures,
except
| ||||||
12 | as specifically provided in paragraph
(14) of subsection b | ||||||
13 | of this Section. | ||||||
14 | (8) Eyeglasses, contact lenses, hearing aids or their | ||||||
15 | fitting. | ||||||
16 | (9) Illness or injury due to acts of war. | ||||||
17 | (10) Services of blood donors and any fee for failure | ||||||
18 | to replace the
first 3 pints of blood
provided to a covered | ||||||
19 | person each policy year. | ||||||
20 | (11) Personal supplies or services provided by a | ||||||
21 | hospital or nursing
home, or any other nonmedical or | ||||||
22 | nonprescribed supply or service. | ||||||
23 | (12) Routine maternity charges for a pregnancy, except | ||||||
24 | where added as
optional coverage with payment of an | ||||||
25 | additional premium for pregnancy
resulting from conception | ||||||
26 | occurring after the effective date of the
optional |
| |||||||
| |||||||
1 | coverage. | ||||||
2 | (13) (Blank). | ||||||
3 | (14) Any expense or charge for services, drugs, or | ||||||
4 | supplies that are:
(i) not provided in accord with | ||||||
5 | generally accepted standards of current
medical practice; | ||||||
6 | (ii) for procedures, treatments, equipment, transplants,
| ||||||
7 | or implants, any of which are investigational, | ||||||
8 | experimental, or for
research purposes; (iii) | ||||||
9 | investigative and not proven safe and effective;
or (iv) | ||||||
10 | for, or resulting from, a gender
transformation operation. | ||||||
11 | (15) (Blank) Any expense or charge for routine physical | ||||||
12 | examinations or tests
except as provided in item (2.5) of | ||||||
13 | subsection b of this Section . | ||||||
14 | (16) Any expense for which a charge is not made in the | ||||||
15 | absence of
insurance or for which there is no legal | ||||||
16 | obligation on the part of the
patient to pay. | ||||||
17 | (17) Any expense incurred for benefits provided under | ||||||
18 | the laws of the
United States and this State, including | ||||||
19 | Medicare, Medicaid, and
other
medical assistance, maternal | ||||||
20 | and child health services and any other program
that is | ||||||
21 | administered or funded by the Department of Human Services, | ||||||
22 | Department
of Healthcare and Family Services, or | ||||||
23 | Department of Public Health, military service-connected
| ||||||
24 | disability payments, medical
services provided for members | ||||||
25 | of the armed forces and their dependents or
employees of | ||||||
26 | the armed forces of the United States, and medical services
|
| |||||||
| |||||||
1 | financed on behalf of all citizens by the United States. | ||||||
2 | (18) Any expense or charge for in vitro fertilization, | ||||||
3 | artificial
insemination, or any other artificial means | ||||||
4 | used to cause pregnancy. | ||||||
5 | (19) Any expense or charge for oral contraceptives used | ||||||
6 | for birth
control or any other temporary birth control | ||||||
7 | measures. | ||||||
8 | (20) Any expense or charge for sterilization or | ||||||
9 | sterilization reversals. | ||||||
10 | (21) Any expense or charge for weight loss programs, | ||||||
11 | exercise
equipment, or treatment of obesity, except when | ||||||
12 | certified by a physician as
morbid obesity (at least 2 | ||||||
13 | times normal body weight). | ||||||
14 | (22) Any expense or charge for acupuncture treatment | ||||||
15 | unless used as an
anesthetic agent for a covered surgery. | ||||||
16 | (23) Any expense or charge for or related to organ or | ||||||
17 | tissue
transplants other than those performed at a hospital | ||||||
18 | with a Board approved
organ transplant program that has | ||||||
19 | been designated by the Board as a
preferred or exclusive | ||||||
20 | provider organization for that specific organ or tissue
| ||||||
21 | transplant. | ||||||
22 | (24) Any expense or charge for procedures, treatments, | ||||||
23 | equipment, or
services that are provided in special | ||||||
24 | settings for research purposes or in
a controlled | ||||||
25 | environment, are being studied for safety, efficiency, and
| ||||||
26 | effectiveness, and are awaiting endorsement by the |
| |||||||
| |||||||
1 | appropriate national
medical speciality college for | ||||||
2 | general use within the medical community. | ||||||
3 | d. Deductibles and coinsurance. | ||||||
4 | The Plan coverage defined in Section 6 shall provide for a | ||||||
5 | choice
of
deductibles per individual as authorized by the | ||||||
6 | Board. If 2 individual members
of the same family
household, | ||||||
7 | who are both covered persons under the Plan, satisfy the
same | ||||||
8 | applicable deductibles, no other member of that family who is
| ||||||
9 | also a covered person under the Plan shall be
required to
meet | ||||||
10 | any deductibles for the balance of that calendar year. The
| ||||||
11 | deductibles must be applied first to the authorized amount of | ||||||
12 | covered expenses
incurred by the
covered person. A mandatory | ||||||
13 | coinsurance requirement shall be imposed at
the rate authorized | ||||||
14 | by the Board in excess of the mandatory
deductible, the | ||||||
15 | coinsurance
in the aggregate not to exceed such amounts as are | ||||||
16 | authorized by the Board
per annum. At its discretion the Board | ||||||
17 | may, however, offer catastrophic
coverages or other policies | ||||||
18 | that provide for larger deductibles with or
without coinsurance | ||||||
19 | requirements. The deductibles and coinsurance
factors may be | ||||||
20 | adjusted annually according to the Medical Component of the
| ||||||
21 | Consumer Price Index. | ||||||
22 | e. Scope of coverage. | ||||||
23 | (1) In approving any of the benefit plans to be offered | ||||||
24 | by the Plan, the
Board shall establish such benefit levels, | ||||||
25 | deductibles, coinsurance factors,
exclusions, and | ||||||
26 | limitations as it may deem appropriate and that it believes |
| |||||||
| |||||||
1 | to
be generally reflective of and commensurate with health | ||||||
2 | insurance coverage that
is provided in the individual | ||||||
3 | market in this State. | ||||||
4 | (2) The benefit plans approved by the Board may also | ||||||
5 | provide for and
employ
various cost containment measures | ||||||
6 | and other requirements including, but not
limited to, | ||||||
7 | preadmission certification, prior approval, second | ||||||
8 | surgical
opinions, concurrent utilization review programs, | ||||||
9 | individual case management,
preferred provider | ||||||
10 | organizations, health maintenance organizations, and other
| ||||||
11 | cost effective arrangements for paying for covered | ||||||
12 | expenses. | ||||||
13 | f. Preexisting conditions. | ||||||
14 | (1) Except for federally eligible individuals | ||||||
15 | qualifying for Plan
coverage under Section 15 of this Act
| ||||||
16 | or eligible persons who qualify
for the waiver authorized | ||||||
17 | in paragraph (3) of this subsection,
plan coverage shall | ||||||
18 | exclude charges or expenses incurred
during the first 6 | ||||||
19 | months following the effective date of coverage as to
any | ||||||
20 | condition for which medical advice, care or treatment was | ||||||
21 | recommended or
received during the 6 month period
| ||||||
22 | immediately preceding the effective date
of coverage. | ||||||
23 | (2) (Blank). | ||||||
24 | (3) Waiver: The preexisting condition exclusions as | ||||||
25 | set forth in
paragraph (1) of this subsection shall be | ||||||
26 | waived to the extent to which
the eligible person (a) has |
| |||||||
| |||||||
1 | satisfied similar exclusions under any prior
individual | ||||||
2 | health insurance policy that was involuntarily terminated
| ||||||
3 | because of the insolvency of the issuer of the policy and | ||||||
4 | (b) has applied
for Plan coverage within 90 days following | ||||||
5 | the involuntary
termination of that individual health | ||||||
6 | insurance coverage. | ||||||
7 | (4) Waiver: The preexisting condition exclusions as | ||||||
8 | set forth in paragraph (1) of this subsection shall be | ||||||
9 | waived to the extent to which the eligible person (a) has | ||||||
10 | satisfied the exclusion under prior Comprehensive Health | ||||||
11 | Insurance Plan coverage that was involuntarily terminated | ||||||
12 | because of meeting a lower lifetime benefit limit and (b) | ||||||
13 | has reapplied for Plan coverage within 90 days following an | ||||||
14 | increase in the lifetime benefit limit set forth in Section | ||||||
15 | 8 of this Act. | ||||||
16 | g. Other sources primary; nonduplication of benefits. | ||||||
17 | (1) The Plan shall be the last payor of benefits | ||||||
18 | whenever any other
benefit or source of third party payment | ||||||
19 | is available. Subject to the
provisions of subsection e of | ||||||
20 | Section 7, benefits
otherwise payable under Plan coverage | ||||||
21 | shall be reduced by
all amounts paid or payable by Medicare | ||||||
22 | or any other government program
or through any health | ||||||
23 | insurance coverage or group health plan,
whether by | ||||||
24 | insurance, reimbursement, or otherwise, or through
any | ||||||
25 | third party liability,
settlement, judgment, or award,
| ||||||
26 | regardless of the date of the settlement, judgment, or |
| |||||||
| |||||||
1 | award, whether the
settlement, judgment, or award is in the | ||||||
2 | form of a contract, agreement, or
trust on behalf of a | ||||||
3 | minor or otherwise and whether the settlement,
judgment, or | ||||||
4 | award is payable to the covered person, his or her | ||||||
5 | dependent,
estate, personal representative, or guardian in | ||||||
6 | a lump sum or over time,
and by all hospital or medical | ||||||
7 | expense benefits
paid or payable under any worker's | ||||||
8 | compensation coverage, automobile
medical payment, or | ||||||
9 | liability insurance, whether provided on the basis of
fault | ||||||
10 | or nonfault, and by any hospital or medical benefits paid | ||||||
11 | or payable
under or provided pursuant to any State or | ||||||
12 | federal law or program. | ||||||
13 | (2) The Plan shall have a cause of action against any
| ||||||
14 | covered person or any other person or entity for
the | ||||||
15 | recovery of any amount paid to the extent
the amount was | ||||||
16 | for treatment, services, or supplies not covered in this
| ||||||
17 | Section or in excess of benefits as set forth in this | ||||||
18 | Section. | ||||||
19 | (3) Whenever benefits are due from the Plan because of | ||||||
20 | sickness or
an injury to a covered person resulting from a | ||||||
21 | third party's wrongful act
or negligence and the covered | ||||||
22 | person has recovered or may recover damages
from a third | ||||||
23 | party or its insurer, the Plan shall have the right to | ||||||
24 | reduce
benefits or to refuse to pay benefits that otherwise | ||||||
25 | may be payable by the
amount of damages that the covered | ||||||
26 | person has recovered or may recover
regardless of the date |
| |||||||
| |||||||
1 | of the sickness or injury or the date of any
settlement, | ||||||
2 | judgment, or award resulting from that sickness or injury. | ||||||
3 | During the pendency of any action or claim that is | ||||||
4 | brought by or on
behalf of a covered person against a third | ||||||
5 | party or its insurer, any
benefits that would otherwise be | ||||||
6 | payable except for the provisions of this
paragraph (3) | ||||||
7 | shall be paid if payment by or for the third party has not | ||||||
8 | yet
been made and the covered person or, if incapable, that | ||||||
9 | person's legal
representative agrees in writing to pay back | ||||||
10 | promptly the benefits paid as
a result of the sickness or | ||||||
11 | injury to the extent of any future payments
made by or for | ||||||
12 | the third party for the sickness or injury. This agreement
| ||||||
13 | is to apply whether or not liability for the payments is | ||||||
14 | established or
admitted by the third party or whether those | ||||||
15 | payments are itemized. | ||||||
16 | Any amounts due the plan to repay benefits may be | ||||||
17 | deducted from other
benefits payable by the Plan after | ||||||
18 | payments by or for the third party are made. | ||||||
19 | (4) Benefits due from the Plan may be reduced or | ||||||
20 | refused as an offset
against any amount otherwise | ||||||
21 | recoverable under this Section. | ||||||
22 | h. Right of subrogation; recoveries. | ||||||
23 | (1) Whenever the Plan has paid benefits because of | ||||||
24 | sickness or an
injury to any covered person resulting from | ||||||
25 | a third party's wrongful act or
negligence, or for which an | ||||||
26 | insurer is liable in accordance with the
provisions of any |
| |||||||
| |||||||
1 | policy of insurance, and the covered person has recovered
| ||||||
2 | or may recover damages from a third party that is liable | ||||||
3 | for the damages,
the Plan shall have the right to recover | ||||||
4 | the benefits it paid from any
amounts that the covered | ||||||
5 | person has received or may receive regardless of
the date | ||||||
6 | of the sickness or injury or the date of any settlement, | ||||||
7 | judgment,
or award resulting from that sickness
or injury. | ||||||
8 | The Plan shall be subrogated to any right of recovery the
| ||||||
9 | covered person may have under the terms of any private or | ||||||
10 | public health
care coverage or liability coverage, | ||||||
11 | including coverage under the Workers'
Compensation Act or | ||||||
12 | the Workers' Occupational Diseases Act, without the
| ||||||
13 | necessity of assignment of claim or other authorization to | ||||||
14 | secure the right
of recovery. To enforce its subrogation | ||||||
15 | right, the Plan may (i) intervene
or join in an action or | ||||||
16 | proceeding brought by the covered person or his
personal | ||||||
17 | representative, including his guardian, conservator, | ||||||
18 | estate,
dependents, or survivors,
against any third party | ||||||
19 | or the third party's insurer that may be liable or
(ii) | ||||||
20 | institute and prosecute legal proceedings against any | ||||||
21 | third party or
the third party's insurer that may be liable | ||||||
22 | for the sickness or injury in
an appropriate court either | ||||||
23 | in the name of the Plan or in the name of the
covered | ||||||
24 | person or his personal representative, including his | ||||||
25 | guardian,
conservator, estate, dependents, or survivors. | ||||||
26 | (2) If any action or claim is brought by or on behalf |
| |||||||
| |||||||
1 | of a covered
person against a third party or the third | ||||||
2 | party's insurer, the covered
person or his personal | ||||||
3 | representative, including his guardian,
conservator, | ||||||
4 | estate, dependents, or survivors, shall notify the Plan by
| ||||||
5 | personal service or registered mail of the action or claim | ||||||
6 | and of the name
of the court in which the action or claim | ||||||
7 | is brought, filing proof thereof
in the action or claim. | ||||||
8 | The Plan may, at any time thereafter, join in the
action or | ||||||
9 | claim upon its motion so that all orders of court after | ||||||
10 | hearing
and judgment shall be made for its protection. No | ||||||
11 | release or settlement of
a claim for damages and no | ||||||
12 | satisfaction of judgment in the action shall be
valid | ||||||
13 | without the written consent of the Plan to the extent of | ||||||
14 | its interest
in the settlement or judgment and of the | ||||||
15 | covered person or his
personal representative. | ||||||
16 | (3) In the event that the covered person or his | ||||||
17 | personal
representative fails to institute a proceeding | ||||||
18 | against any appropriate
third party before the fifth month | ||||||
19 | before the action would be barred, the
Plan may, in its own | ||||||
20 | name or in the name of the covered person or personal
| ||||||
21 | representative, commence a proceeding against any | ||||||
22 | appropriate third party
for the recovery of damages on | ||||||
23 | account of any sickness, injury, or death to
the covered | ||||||
24 | person. The covered person shall cooperate in doing what is
| ||||||
25 | reasonably necessary to assist the Plan in any recovery and | ||||||
26 | shall not take
any action that would prejudice the Plan's |
| |||||||
| |||||||
1 | right to recovery. The Plan
shall pay to the covered person | ||||||
2 | or his personal representative all sums
collected from any | ||||||
3 | third party by judgment or otherwise in excess of
amounts | ||||||
4 | paid in benefits under the Plan and amounts paid or to be | ||||||
5 | paid as
costs, attorneys fees, and reasonable expenses | ||||||
6 | incurred by the Plan in
making the collection or enforcing | ||||||
7 | the judgment. | ||||||
8 | (4) In the event that a covered person or his personal | ||||||
9 | representative,
including his guardian, conservator, | ||||||
10 | estate, dependents, or survivors,
recovers damages from a | ||||||
11 | third party for sickness or injury caused to the
covered | ||||||
12 | person, the covered person or the personal representative | ||||||
13 | shall pay to the Plan
from the damages recovered the amount | ||||||
14 | of benefits paid or to be paid on
behalf of the covered | ||||||
15 | person. | ||||||
16 | (5) When the action or claim is brought by the covered | ||||||
17 | person alone
and the covered person incurs a personal | ||||||
18 | liability to pay attorney's fees
and costs of litigation, | ||||||
19 | the Plan's claim for reimbursement of the benefits
provided | ||||||
20 | to the covered person shall be the full amount of benefits | ||||||
21 | paid to
or on behalf of the covered person under this Act | ||||||
22 | less a pro rata share
that represents the Plan's reasonable | ||||||
23 | share of attorney's fees paid by the
covered person and | ||||||
24 | that portion of the cost of litigation expenses
determined | ||||||
25 | by multiplying by the ratio of the full amount of the
| ||||||
26 | expenditures to the full amount of the judgement, award, or |
| |||||||
| |||||||
1 | settlement. | ||||||
2 | (6) In the event of judgment or award in a suit or | ||||||
3 | claim against a
third party or insurer, the court shall | ||||||
4 | first order paid from any judgement
or award the reasonable | ||||||
5 | litigation expenses incurred in preparation and
| ||||||
6 | prosecution of the action or claim, together with | ||||||
7 | reasonable attorney's
fees. After payment of those | ||||||
8 | expenses and attorney's fees, the court shall
apply out of | ||||||
9 | the balance of the judgment or award an amount sufficient | ||||||
10 | to
reimburse the Plan the full amount of benefits paid on | ||||||
11 | behalf of the
covered person under this Act, provided the | ||||||
12 | court may reduce and apportion
the Plan's portion of the | ||||||
13 | judgement proportionate to the recovery of the
covered | ||||||
14 | person. The burden of producing evidence sufficient to | ||||||
15 | support the
exercise by the court of its discretion to | ||||||
16 | reduce
the amount of a proven charge sought to be enforced | ||||||
17 | against the recovery
shall rest with the party seeking the | ||||||
18 | reduction. The court may consider
the nature and extent of | ||||||
19 | the injury, economic and non-economic loss,
settlement | ||||||
20 | offers, comparative negligence as it applies to the case at
| ||||||
21 | hand, hospital costs, physician costs, and all other | ||||||
22 | appropriate costs.
The Plan shall pay its pro rata share of | ||||||
23 | the attorney fees based on the
Plan's recovery as it | ||||||
24 | compares to the total judgment. Any reimbursement
rights of | ||||||
25 | the Plan shall take priority over all other liens and | ||||||
26 | charges
existing under the laws of this State with the |
| |||||||
| |||||||
1 | exception of any attorney
liens filed under the Attorneys | ||||||
2 | Lien Act. | ||||||
3 | (7) The Plan may compromise or settle and release any | ||||||
4 | claim for
benefits provided under this Act or waive any | ||||||
5 | claims for benefits, in whole
or in part, for the | ||||||
6 | convenience of the Plan or if the Plan determines that
| ||||||
7 | collection would result in undue hardship upon the covered | ||||||
8 | person. | ||||||
9 | (Source: P.A. 95-547, eff. 8-29-07; 96-791, eff. 9-25-09; | ||||||
10 | 96-938, eff. 6-24-10.)
|