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Danvers, MA 01923

(866) 630-CPSC Toll-free
(978) 774-0540 Facsimile

www.CPSCmsa.com

In a decision dated November 6, 2007, the United States District Court, Michigan Southern Division, found in favor of Medicare, granting its Motion for Summary Judgment and dismissing Medicare from the third party action in Fujitsu Ten Corp. of America Employee Ben. Plan-Indiana Employees v. Unicare Life & Health Ins. Co., 2007 WL 4234105 (E.D. Mich. 2007). The underlying Fujitsu litigation concerns an ERISA dispute over the responsible primary payer for approximately $500,000 in medical expenses incurred by the decedent, Steven Coyle. In June 2006, Defendant Uticare filed a third-party complaint against Medicare, seeking to declare Medicare as the primary payer for said medical expenses. In response, Medicare filed a Motion for Summary Judgment, which came before the Court, as all parties to the action agreed that there were no genuine issues of material fact in dispute.

The undisputed facts of this multiple-coverage case are such that Mr. Coyle, who was diagnosed with numerous, serious medical conditions in 2003, was covered under two private health care plans, as well as Medicare. That is, Mr. Coyle was covered under a heath care policy from his employer, Visteon, from which he retired and enrolled in their plan as a retiree in 1999. In addition, he was covered by a large group, private health plan in the years 2002-2005, through his wife’s employment at Fujitsu. On September 1, 2002, Mr. Coyle had also become entitled to Medicare on the basis of disability.

Though Mr. Coyle was a Medicare beneficiary, Medicare maintained that it was not a primary, but rather a secondary payer for medical expenses incurred by Mr. Coyle under the federal Medicare Secondary Payer Statute (“MSP”) and the facts of the case. However, as the third-party complaint sought only declaration of the primary payer, the Court did not formally adjudicate whether Medicare was secondarily responsible, and determined only that Medicare could not be deemed the primary payer. By Defendant Utica’s own admission, there could be only one primary payer in a situation involving an individual with multiple health plan coverage. Furthermore, under the MSP, Medicare could only be—at a maximum—secondarily responsible for Mr. Coyle’s medical expenses, as he was already enrolled and covered under a health plan.

By Collin McDonald, Esq., Legal Counsel for Crowe Paradis Services Corporation

Did You Know?
Your MSA Vendor Should...

- Texas is the only state that allows any private sector employer the option of not purchasing workers’ compensation coverage for employees (also known as “nonsubscription” to the Texas workers’ compensation system).

- Although most states have mandatory workers’ compensation coverage requirements, certain states do not require workers’ compensation coverage for particular industries. For example, in states such as Georgia, Kansas, Missouri, Nebraska, and Wyoming workers’ compensation coverage is elective for certain agricultural employers.

- Approximately 14 states with compulsory workers’ compensation laws provide exemptions for small private sector employers:

* Four states exempt employers with fewer than five employees
* Two states exempt employers with fewer than four employees
* Seven states exempt employers with fewer than three employees
* One state exempts employers with one employee

- The vast majority of states (45 states) do not place any statutory limitations on medical benefits, including the length of time an injured worker may receive medical care related to an on-the-job injury or the total amount of money that can be spent on medical care related to an on-the-job injury.

* Two states require injured workers to pay a co-payment for medical services under certain circumstances
* One state places limits on psychological treatment if not based on a referral from a physician
* One state specifies that once the injured worker has received TTD benefits for ninety days, the worker must be evaluated by the exclusive state fund to determine continued eligibility for income benefits and the appropriateness of the medical treatment.
* One state ends employer liability for medical care after six months if the worker has never lost time away from work, returned to work for at least six months, or a maximum of $10,000 has been paid, unless the employer agrees to extend the time and dollar limits.

Taken from “COMPARISON OF STATE WORKERS’ COMPENSATION SYSTEMS “ Texas Department of Insurance, WC Research Group.

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