ERISA Update: Sixth Circuit Decision Reminds To Review Plan Documents Carefully

On August 1, 2023, the United States Court of Appeals for the Sixth Circuit issued its decision in Patterson v. United HealthCare Insurance Company.  The Court’s decision serves as a reminder to carefully scrutinize health plan provisions when dealing with plan reimbursement claims.

Eric Patterson was injured in an auto accident.  United HealthCare paid for Patterson’s medical care but, afterward, attempted to recover those payments from a claim Patterson made against the at fault driver.  Patterson initially recognized the validity of UHC’s claim based upon the summary of the underlying health plan, but later learned – after he had paid a portion of the recovery to UHC – that the health benefit plan did not recognize a right to reimbursement by UHC.  The Sixth Circuit ultimately determined that Patterson had the right to sue UHC for claims under ERISA, due to the improper claim that UHC had made for reimbursement in the first place.

The Patterson case is a reminder to providers and patients to carefully scrutinize ERISA plan provisions.  Providers and patients often find themselves adverse to health plans seeking reimbursement from third-party sources.  When such situations arise, providers and patients should ensure that the health plan provisions support the asserted reimbursement claims.

If you have questions about this or any other medical reimbursement issue, please contact Joseph Gavin or any one of our provider reimbursement counsel at mjmedrecovery.com