Wednesday, September 30, 2009

SSDI (Social Security Disability Insurance) Inquiry

Posted by Carol Brown

Question:
I represent a gentleman who was rear ended by a truck. As a result of the accident, he is receiving social security disability benefits. Is social security entitled to subrogation regarding benefits paid?

Answer:
Social Security Disability Insurance (SSDI) is an entitlement program based on a person’s prior work history and disability qualifiers. Social Security does not have a statutory right of reimbursement for disability benefits paid in liability situations. However, generally SSDI beneficiaries under age 65 are eligible for Medicare coverage in the month after they have received 24 months of SSDI benefits. There is a five-month waiting period from onset of the disabling condition for disabled individuals to be qualified to receive SSDI benefits. As a result of this waiting period, there is a total of 29 months after the onset of the disability before an individual is eligible for Medicare benefits.

Having said that, if your client becomes eligible for Medicare prior to settlement and/or is still treating for accident related care it is important to note that CMS has a direct right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, state agency, or a private insurer that has received a third party payment, 42 CFR 411.24. MSP laws are applicable to situations where a beneficiary may file a claim and/or a civil action against a third party seeking damages for injuries received and medical expenses incurred as a result of that illness/injury. Per 42 U.S.C. 1395y(b) (2) and 1862 (b) (2)(A)(ii) of the Act, Medicare is precluded from paying for a beneficiary's medical expenses when payment "has been made or can reasonably be expected to be made under a workers' compensation (WC) plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.

Hope you find this helpful. If we can assist you in the future, please do not hesitate to contact me.

Carol Brown

Tuesday, September 29, 2009

Tri-Care Subrogation Claim

Posted by Michael Russell

Question:
Can you request a subrogation claim from Tri-Care if you are a defendant in a personal liability case in MN and this is being done 2+ years later?

Answer:
I apologize but from the wording of your question I am unable to determine the exact thrust of the inquiry. If you could provide further details in terms of what you are requesting and who you are requesting from, I would be happy to elaborate on my answer.

Tri-Care derives the authority to assert a subrogation claim under 42 U.S.C. §§ 2651-2653, which authorizes recovery of the reasonable value of medical care furnished or paid for by the United States under circumstances creating tort liability for such medical care in a third party. 32 C.F.R. § 199.12(b).

In the state of MN personal injury claims and property damage claims based upon negligence must be brought within 6 years. Thus the fact this is 2+ years later will not matter.

I hope you found this somewhat helpful and again I am happy to respond if further info is provided. Thanks.

Michael Russell

Monday, September 28, 2009

Can Medicare Recover From An Estate?

Posted by Mary Skinner

Question:
My mother just recently passed away and has left a small estate of 3 properties and some amount of CD's to me and my 2 bothers. I just learned from an Arkansas Lawyer that our estate will go into probate for all creditors to be paid including Medicare. Can Medicare make a claim? We spend our whole working lives paying into Medicare and now I am hearing that after my mother dies she now has to repay for the services she needed while disabled. Where can I find this federal or state law that states that Medicare can take an estate?

Arkansas Attorney

Answer:
Medicare does not have a right to recover from the estate unless your mother or her estate has filed a claim against another party for injuries sustained as a result of their wrongdoing and received a settlement. The only time that Medicare can assert a claim (lien) against the estate is IF your mother was injured and as a result there was a claim initiated against a third party who was responsible for the injury and received a settlement. If Medicare made payments for claims (conditional payments) that were for the treatment of the injury then Medicare can recover those payments from the settlement and the estate.

The regulations regarding Medicare's right to reimbursement on conditional overpayments in liability situations can be found under 42 CFR s411.23, 411.24,411.26,411.37,411.50,411.52, and 411.54. It is important to note at this point that "liability insurance" means insurance (including a self-insured pan) that provides payment based on legal liability for injury or illness or damage to property. It includes, but is not limited to automobile liability insurance, uninsured motorist insurance, underinsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance. These regulations also established that Medicare would be secondary to no-fault insurance, which is defined as "insurance that pays for medical expenses for injuries sustained on the property or premises of the insured." This insurance includes, but is not limited to automobile, homeowners, and commercial plans. This insurance is sometimes called "medical payments coverage", "personal injury protection", or "medical expense coverage". 42 CFR ss411.50

I hope this helps.
Mary Skinner

ERISA Health Care Plan Language

Posted by Michael Russell

Question:
My client has a self funded ERISA health care plan. A plan participant's dependent was hurt during childbirth and a lawsuit ensued. The hospital and the plaintiffs have agreed, in principle, to settle the claim for 2 million dollars.

In exchange for reimbursement of all past plan funds expended on medical care for the dependent, the plaintiffs have asked the plan to waive all future rights to subrogation from the settlement funds.

The plan does not have crystal clear language as to whether it is entitled to the future funds. Is there anything else in particular to be looking at when advising my client whether or not to take the deal offered? For what it is worth, my heart is voting for settling the claim.

Texas Attorney

Answer:
Subrogation and reimbursement rights are governed largely by the plan language itself. In this case I would look to the recovery elements that the Plan claims an interest. Here we are talking about whether or not a Plan is entitled to receive a credit against future benefits. To my knowledge the 5th circuit has not dealt directly with this issue. Generally, a Plan will be entitled to reimbursement only for payments made prior to the time the Plan participant settles UNLESS there is specific language creating a right to this credit or the plan has some type of exclusionary language.

- 7th circuit
o No future credit unless specific language (express clause required)
- 9th
o Exclusionary clause can achieve same result as credit
• Refusal to pay tortfeasor caused injuries unless payment considered advancement and granted lien

Because the Plan does not have crystal clear language it would seem there would not be a reimbursement right for future expenses from the settlement funds. Another thing to consider is the language of the settlement agreement. If the settlement funds were allocated for particular damages it could also affect right to future credit (ex. None of these funds are intended to cover future medical expenses/ claims for future medical are waived hence no reimbursement right). I hope you find this helpful and please let me know if you have any additional questions.

Michael Russell

Wednesday, September 23, 2009

Small Claims Settlements

Posted by Mary Skinner

Question:
I have a small claim that was settled by letter and negotiations. There were no legal documents filed. Does Medicare need to be notified?

Thank you in advance.

Michigan Attorney

Answer:
Yes, any settlement that involves a Medicare beneficiary must be reported and Medicare's interest protected.

Section 42 CFR 411.23 states that a beneficiary must cooperate in any action taken by the Centers for Medicare and Medicaid Services in recovering conditional payments. Failure to do so or not protecting the Medicare program during and after settlement negotiations may result in CMS taking action against the beneficiary to collect the mistaken payment.
In the event that reimbursement is not made to Medicare as required by 42 USC 1395y(b)(2)(B)(I), action may be brought against any entity responsible for payment (and may collect double damages from insurance companies), or any entity that has received a third-party settlement. Under 42 CFR 411.24(g), this includes attorneys whose fees are paid from settlement proceeds. Please refer to US v. Sosnowski, et. al. where judgment was entered against a beneficiary and his attorney for failing to reimburse Medicare after receiving settlement proceeds on a personal injury case.

CMS has a direct right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, State agency, or a private insurer that has received a third party payment, 42 CFR 411.24.

In addition, Medicare has the authority to refer non-collectible debts over to the United States Department of Treasury for possible offset of a beneficiary's benefits.

The regulations regarding Medicare's right to reimbursement on conditional overpayments in liability situations can be found under 42 CFR s411.23, 411.24,411.26,411.37,411.50,411.52, and 411.54. It is important to note at this point that "liability insurance" means insurance (including a self-insured pan) that provides payment based on legal liability for injury or illness or damage to property. It includes, but is not limited to automobile liability insurance, uninsured motorist insurance, underinsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance. These regulations also established that Medicare would be secondary to no-fault insurance, which is defined as "insurance that pays for medical expenses for injuries sustained on the property or premises of the insured." This insurance includes, but is not limited to automobile, homeowners, and commercial plans. This insurance is sometimes called "medical payments coverage", "personal injury protection", or "medical expense coverage". 42 CFR ss411.50

Hope this is helpful, Mary Skinner

Tuesday, September 22, 2009

Made Whole Issues

Posted by Michael Russell

Question:
I need some fresh thoughts on a made whole issue I am briefing. Here’s the scenario: Client is severely injured in a collision. Health insurer pays substantial medical bills. Tortfeasor's limits are inadequate, but it's all we can get. Health insurer's subrogation provision does not contain Lawson language, so the made whole rule applies. (The insurer concedes this point.) The issue becomes whether client received "full compensation." Health insurer argues that the total of compensation received must include the amount of the subrogation interest and quotes Copeland Oaks ("The made-whole rule provides that an insurer cannot enforce its subrogation rights unless and until the insured has been made whole by any recovery, including any payments from the insurer.") I think this argument is a stretch, and there is some helpful language in Blue Cross v. Hrenko. Why does the subrogation interest get to be added into the amount of compensation - making "full compensation" more easily in reach?

-Ohio Attorney

Answer:
The determination of what elements make an insured ‘made whole’ vary from court to court. Unfortunately Copeland Oaks does consider insurer benefits in its made whole calculation and the case has been cited 14 times for this issue. I haven’t found any cases which state the opposite- that insurer benefits should not be included in make whole determinations. However I did come across Minnesota’s subrogation statute which specifically excludes such benefit payments (“full recovery does not include payments made by a health Plan to or for the benefit of a covered person” MSA 62A.095(2)). Maybe something to go on or argue…

Mike Russell

Monday, September 21, 2009

CMS Set Aside, Attorney Fees

Posted by John Cattie

Question:
Am I correct in my understanding that attorney fees as procurement costs are only allocable to Medicare where past medical benefits paid by Medicare are being settled or compromised along with past wage loss benefits (i.e. claim petitions)?

-Pennsylvania Attorney

Answer:
Correct – as we currently sit, Medicare does not allow the procurement costs of a case to be allocated to satisfaction of Medicare’s future interests (i.e. MSA evaluation and/or MSA set up). The procurement costs may only be allocated to satisfaction of Medicare’s past interests (i.e. conditional payments or CPs it may have made from date of injury to date of settlement). In the future, it may be possible to allocate procurement costs to satisfaction of Medicare’s future interests as is set forth in HR 2641, a piece of legislation sitting with the House Ways and Means Committee that purports to create safe harbors and bright line rules in the area of Workers’ Comp MSAs. Until that day (or CMS tells us otherwise), procurement costs may only be allocated to verification and resolution of the CPs paid for injury-related care from date of injury to date of settlement.

Kindest regards,

John Cattie

Friday, September 18, 2009

Past Payments Made By Medicare

Posted by Sylvius Von Saucken

Question:
I understand that no MSA is required on a medical malpractice case but that doesn't answer the question whether Medicare can post settlement refuse to pay claims in light of 1395Y(b)(2)(A)(i). Do you think we should be telling our clients that it might be a possibility?

Also, in mediation, do you suggest we avoid submitting written itemizations of damages that include large components of future medical expense that would ordinarily be covered by Medicare?

Thanks in advance for your thoughts.
Ohio Attorney

Answer:
You raise a very good point, given the fact that the statutory language of sub(b)(2)(A)(i) from 42 U.S.C. §1395y refers to "payments made or to be made". However that subsections goes on to exempt from immediate recovery those payments made on a conditional basis.

When read in conjunction with subpara. (b)(2)(B) (conditional payments Medicare can make, subject to recovery), and when considering the MSP Statute in light of recent CMS clarifications concerning the Medicare reporting rules for Responsible Reporting Entities (insurance companies), effective July 1, 2009, for settlement occurring on or after Jan. 1, 2010, the statutory construct clearly refers to past payments made by Medicare, or to payments Medicare should not make based on its secondary payer status.

In the case then of a WC settlement, clients should be told that there is a possibility that Medicare can refuse to pay a medical claim unless its interests were properly considered as part of the settlement process. In the case of a medical malpractice (liability) case, however, the same analysis whether there exists a future cost of care and a permanent burden shift, combined with a future medical allocation and properly documented file will be the best way to then determine what, if anything, you need to tell the clients.

Until further statutory evidence, interpretations or case law is presented that proves the MSP Statute is intended to apply to future costs of care and not just conditional payments; as even the rules for double damage for attorneys and the broad liability to attorneys and settling parties alike for non-compliance only apply to conditional payments (rather than future ones), we would not recommend advising your clients that Medicare would challenge their future medical claims absent the proper analysis of the case.

To the extent that the mediation does not result in a specific, carved out amount of future medical expenses to be paid, whether you also discuss or review future medicals to build your damage analysis is not dispositive of the question whether or not a MSA should be considered.

Simply put, if it is in your client's best interests to submit life care plans and other evidence of damages, you should continue to do so. That type of evidence, while probative of arguments for damages leading to settlement do not, unless the parties agree, result in a line item for future medicals that would, in our opinion, trigger the need to consider whether there also exists a permanent shift of the burden of paying for those future medical expenses (over to Medicare). It is those two critical elements, and not the existence of a life care plan or similar documents, that can lead to the need to properly consider Medicare's interests through the use of a MSA.

To be clear, there are very limited instances when we see liability MSAs. Those include jury verdict sheets, the settlement of cases which are greater than maximum caps on damages under state law would permit, or the existence of an injury that the parties all understand will require future costs of care such as the loss of a limb for someone who is entitled to Medicare - Medicare would pay the costs of prosthetics and no amount of arguing would prevent the parties from recognizing the existence of future costs of care. However, even in that case, if there is another source of coverage, there may not be a permanent burden shift. As discussed, you need both conditions to be met before you can move forward with determining whether a MSA will be needed to properly consider Medicare's interests.

Please let us know if you have any follow up questions.

Our best,
Sylvius von Saucken, J.D.

Thursday, September 17, 2009

MSA Guidelines In Liability Cases

Posted by Mary Skinner

Question:
My client fell in December 2007 and had to undergo a total knee replacement in 2008. All medical coverage provided through her employer's group plan; with a 3rd party lien of $55k. My client retires in June 2009 at age of 72. The client's primary insurance is now Medicare. Should we go through a CMS Review to determine whether or not a MSA will be required for questionable future follow-up care?

Hawaii Attorney

Answer:
Not necessarily. CMS has not issued any guidelines regarding MSA in liability cases and until we receive guidance from CMS about the use of MSAs in liability cases, the most important thing you can do is document your efforts at considering Medicare's interests. Whether that documentation comes in the form of an internal memo within your firm, notes from a telephone consultation on the case, language inserted within the settlement agreement itself, or an MSA evaluation from an independent, neutral 3rd party like GFRG, documenting your efforts to substantially comply with 42 U.S.C. 1395y(b)(1) will serve to show Medicare that you indeed did make a good faith effort at protecting its interests. In turn, you will be protecting your client's Medicare benefits.

GFRG generally only recommends an MSA be established in a liability case when:1.) The liability settlement is above $800K in gross recovery or there is a judicial allocation/verdict for future medicals regardless of the settlement amount. 2.)There is going to be a permanent shift of the burden of paying future injury-related medial expenses from the liable third party to Medicare; and 3.) The settlement contemplates future injury-related expenditures. If you do not have any of these elements, you do not need to consider an MSA.

Based upon the information you provided, at face value your case does not look like an LMSA candidate. Of course, the appropriate measures need to be taken to reimburse Medicare for past injury-related care even though Medicare was secondary the fact that he had Medicare requires that notify Medicare. Additionally, I recommend that you memorialize in your file the internal evaluation in regards to the necessity of an LMSA.

The only liability case wherein Medicare contends that it is clear an obligation exists is a case involving a Medicare beneficiary where there is a defined judicial allocation for future medicals (i.e. an interrogatory / verdict sheet with a definitive allocation for future medicals).

I hope this helps.
Mary Skinner

Should We Have A MSA For Workers Compensation

Posted by John Cattie

Question:
My old firm is pretty close to settling the civil portion of a workers compensation case that I have. We are probably going to settle the WC case for a dollar with a lien waiver. My client is on Social Security disability. If we settle the WC case for a dollar, do we have to have a Medicare Set Aside? The settlement on the third party will probably be around 200k.

Illinois Attorney

Answer:
We know from the April 2003 CMS Memo that settlements containing both a Workers Compensation component as well as a liability component should be treated akin to WC cases for MSA purposes. Therefore, the fact that the parties in the WC case are settling for a dollar with a lien waiver will not shield the claimant from the MSA requirement. The focus should be on who will be paying for future meds going forward. If the burden of making those payments is being shifted from the WC carrier to Medicare going forward, and the claimant will require future injury-related care, then a MSA may be appropriate.

John Cattie

Wednesday, September 16, 2009

ERISA Inquiry

Posted by Michael Russell

Question:
My client lost a foot in an accident. The ERISA plan paid $59,000 in medical benefits and the only insurance is a $25,000 uninsured motorist policy which limits have been tendered. The plan demands the whole $25,000. They filed a motion for the same. Their plan language says their "first priority" and what they are entitled to regardless of "made whole." Any thoughts on how to get my client something while, the plan, without doing anything to recoup its losses in regard to the liability claim now just demands every penny of the settlement?

Thank you.

Answer:
First and foremost, the status funding of the plan needs to be determined. Generally the language of the Summary Plan Description and the Form 5500 and corresponding schedule A(s) are used to determine the funding status. These documents and other plan document information can be requested from both the employer and insurer or third party administrator.
If self-funded, then ERISA would pre-empt state law under section 1003(a). Thus we would look to the seventh circuit. Possible defenses…
1. Specific Fund Doctrine
a. Party must be seeking to impose constructive trust or equitable lien on specifically identifiable property rather than attempting to impose personal liability
i. Ask two questions regarding the PLAN language
1. Does it specify that plan recover specifically from settlement award?
2. Does it specify that plan can recover only up to amount paid?
ii. If no, it is likely that the lien unenforceable
2. Made Whole Doctrine (7th circuit is default jurisdiction)
a. Thus doctrine may be abrogated by clear and unambiguous language. Plan’s language that you note seems to do this.
b. No help here.
3. Common Fund Doctrine (plan’s recovery is reduced so it bears proportion of attorneys fees and costs)
a. Common fund doctrine applies in seventh circuit unless plan specifically provides that beneficiary is responsible for all attorney’s fees. 338 F.3d 680
b. The first priority language may overcome this argument but worth a try.
c. Reduce demand by % of fees.
4. Other
a. Does the plan limit recovery to settlement amounts allocated for medical expense? If so what amount was allocated for medical expenses?

If insured, then state law defenses would be available under section 1144(b)(2)(A). Under Wisconsin…
1. Made whole doctrine
a. May be abrogated by plan language – that is the case here. No help.
2. Common Fund Doctrine
a. Applies if
i. Money recovered solely by efforts of attorney
ii. Notice given that action commenced and reasonable fee requested
iii. And carrier does not become party to action1. 162 Wis.2d 821
3. Specific Fund
a. See above
4. Uninsured Motorist Coverage
a. Depending on the language of the plan, the carrier may or may not be able to subrogate itself against the UM carrier.

I hope you find this response helpful in addressing your client’s situation. Although, we are unable to make a definite determination at this time we would be happy to provide a full evaluation if you could provide us with the information above. Please let me know if you have any questions and please let me know how we can provide further assistance. Thank you and I look forward to your response.

My Best,
Michael Russell

Monday, September 14, 2009

Estate Letter Request For Medicare

Posted by Mary Skinner

Question:
We just settled a MVA case and are working on our demand letter request for Medicare. The beneficiary is now deceased. Medicare never filed a claim in the estate and we joined Medicare as a party to the suit and they did not file an answer. Can we default them on their lien or because they did not file a claim against the estate, is its lien still valid?

Thanks,
Indiana Attorney

Answer:
Medicare’s lien is still valid, they do not have to file a claim against the estate as they have a priority right of recovery. The death of a beneficiary does not materially change Medicare's interest in recovering it's benefits made on the behalf of the beneficiary while still alive.
Section 42 CFR 411.23 states that a beneficiary must cooperate in any action taken by the Centers for Medicare and Medicaid Services in recovering conditional payments. Failure to do so or not protecting the Medicare program during and after settlement negotiations may result in CMS taking action against the beneficiary to collect the mistaken payment.
In the event that reimbursement is not made to Medicare as required by 42 USC 1395y(b)(2)(B)(I), action may be brought against any entity responsible for payment (and may collect double damages from insurance companies), or any entity that has received a third-party settlement. Under 42 CFR 411.24(g), this includes attorneys whose fees are paid from settlement proceeds.

Additionally, if you have sent the MSPRC an authorization signed by the client prior to their death that authorization is no longer valid. In order to receive information from the MSPRC at this point you will need to send in a new authorization signed by the executor/administrator of the estate along with the Letter of Testimary from the court.

Regards,
Mary Skinner

Friday, September 11, 2009

ERISA Lien Waived?

Posted by Michael Russell

Question:
I wrote to a client’s carrier and requested proof of the ERISA plan. There was no reply after more than 30 days. The client wants me to settle the claim. Can the ERISA claim be waived due to no response? If so, is there any authority for this?

Thanks,
Washington Attorney

Answer:
Under ERISA (section 1024(b)(4)) an administrator must make plan materials available and furnish copies of such upon request. Case law says that this request must be sufficiently specific. Your email below does not mention whether or not specific documents were requested (SPD, Form 5500, etc) but if the request mentioned ERISA it would seem to be specific enough.

Under section 1132(c)(1) if the administrator fails to honor a request within 30 days, the administrator can be subject to statutory civil penalties of up to $100 a day. However, this failure to respond does not result in a waiver of claim(s).

Mike Russell

Thursday, September 10, 2009

Appealing Charges Connected With Medical Procedures

Posted by Mary Skinner

Question:
My client injured their right knee in a 2004 car accident. The client was treated with arthroscopic surgery and physical therapy for about nine months followed by a right knee replacement short after. In 2006, the client became Medicare eligible and had their knee replacement removed due to an infection, and then replaced with a second prosthesis. From there he had DVT treatment and related vascular care. Also, he had a totally unrelated fall with a hip fracture and replacement in 5/2008. Although the clients knee injury's infection and subsequent two surgeries were alleged as damages in the law suit, causal connection was very weak and we settled the case for $90K. I objected to CMS initial reimbursement amount. Its final repayment demand of $49K will leave the client with practically no recovery. Please answer the following questions: 1. Why won't CMS remove the unrelated hip fracture charges? 2. What is the best strategy to appeal the charges for the tenuously connected medical procedures and hip fracture?

Thanks in advance,
New York Attorney

Answer:
First and foremost, the final demand must be paid back to Medicare within 60 days of the issue date otherwise interest will accrue regardless of any future arguments you present to Medicare.

Medicare will remove the unrelated hip fracture charges if you provide them with documentation that states the charges are not related to your clients’ 2004 injury. As or a strategy to appeal the other charges, the best approach would be to request a post settlement compromise and provide any documentation you can to support your argument. Given the settlement amount and Medicare's demand it has been our experience that Medicare will usually do a 1/3 split between all parties.

Mary Skinner

Is MSA Subject To A Lien For Back Child Support

Posted by John Cattie

Question:
I have a client who has received a workers’ compensation settlement with a Medicare Set Aside account. The State of Illinois has submitted a lien for back child support. It is our position that Medicare Set Aside account is not subject to lien but we cannot find any information on point. Do you have any suggestions? The State of Illinois wants documentation from us stating that account is not subject to lien.

Thank you,
Illinois Attorney

Answer:
The purpose of a Medicare Set Aside is to protect Medicare's future interests by setting aside that portion of a claimant's workers' compensation settlement allocated to future medical expenses which would otherwise be covered by Medicare. Since Medicare is the payer of last resort under the Medicare Secondary Payer Act, the MSA ensures that its interests are being properly protected. The only appropriate use of MSA proceeds is to pay for future injury-related care otherwise covered by Medicare. The claimant is not protecting Medicare's interests if he/she uses MSA proceeds for expenses other than future injury-related care otherwise covered by Medicare. Therefore, it would be inappropriate to pay any lien obligations out of the MSA, including liens for back child support.

John Cattie

Tuesday, September 8, 2009

ERISA, Furnishing Summary Plan Description

Posted by Michael Russell

Question:
Must a participant/beneficiary sign something showing receipt of the summary plan description? Who has the burden of proving that the beneficiary received the SPD?

Answer:
ERISA does not require that a participant/beneficiary sign anything upon receipt of the Summary Plan Description. Under ERISA, 29 USC § 1024(b)(1), the administrator must furnish the beneficiary with a copy of the SPD. However ERISA does not provide standards to judge whether or not this duty of disclosure has been met.

The burden of proving receipt will generally fall upon the administrator. However the burden is very light and in most cases liability will not be imposed unless a request was made by the beneficiary. More importantly, to receive damages the beneficiary must show substantive harm or prejudice (§ 1104).

Case law regarding basic furnishment of the SPD is very sparse. However if the case involves a beneficiary's request for documentation and subsequent denial, the burden upon the administrator becomes much heavier. However even in these situations, the failure to provide does not change the language or terms of the policy.

I hope this information helps.

Mike Russell