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Do I have to self report about subrogation to ERISA health insurance plan?

Lakewood, WA |

I am in state of WA.
I was rear ended in may 2010 but no PIP or health insurance..started health insurance in 2012 and I have visited some specialists for injuries from that accident in 2010.
I have not hired a lawyer and have not filed any law suit for this personal injury case, at least not as of now.
I have not been notified about any subrogration lien or documents by my health insurance plan.
Now I have two questions...
1.Do I have self report about potential settlement or after settlement? or its like... if they did not notify me about any subrogation interest or any lien ...I should not worry about reimbursing them?

2.If I settle with third party auto insurance and have them write a letter saying 'that they are not paying any of my medical I still liable to reimburse ?

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Attorney answers 6

Best Answer

First, I would take a look at your Summary Plan Descriptio (SPD) and also the full Plan to determine what your rights and duties are under The Plan. Undoubtedly, there is a section in there on subrogation. ERISA is a very complicated topic and there have been some recent changes in the 3rd and 9th Circuits regarding equitable defenses and reimbursement. You would be well served to speak with an attorney who is knowledgeable on this subject so that you don't do anything you may later regret.


Arthur D. Leritz

Legal Disclaimer: Mr. Leritz is licensed to practice law in the State of Washington. The response herein does not constitute legal advice nor does it seek to establish an attorney/client relationship, but rather offers educational insight only. Please feel free to visit Mr. Leritz's website for additional information:


You need to hire an attorney straight away. Good luck Sir.

You should consult an attorney in your State at once. Visit our webpage and tell us what you think.


The recommendation I give to my clients is: if health insurance has paid medical bills that are related, or might be considered to be related, to the accident then health insurance should be contacted to verify the existence or non-existence of a lien or subrogation claim. This usually gives my clients peace of mind. However, I would recommend talking to an attorney in your area familiar with this area of law who might be able to do this in the most advantageous way.


I agree with the others that responded. You should look at your health insurance policy and see what it requires. Its pretty obvious you want to maximize your claim but you are likely leaving money on the table without an attorney. Good luck.

I am an Arizona attorney. AVVO does not pay us for our responses. Simply because I responded to your question does not mean I am your attorney. In Arizona a non-lawyer is held to the same standards as an attorney so there are dangers to representing yourself. This is for informational purposes only and should not be considered as legal advice. If you require legal assistance an in depth discussion of your case is needed as there are many other issues to consider such as defenses, statute of limitations, etc.



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ERISA is an odd world. However, I would be reluctant to play hide and seek with the carrier's rights. Once the carrier has paid benefits to you or on your behalf they have bought your rights. You generally have a loss reporting duty to cooperate in the claim and pass through any documentation related to any claim. Regardless of the fine print in your policy, double dipping will never make you look good to a finder of fact. If you have decorated the facts to make a non covered loss (car accidents can be excluded from health coverage) look like a covered a sports may already have technically committed insurance fraud. Yoy really should consult an ERISA experienced employment and benefits attorney to help you understand your situation and how best to clean it up.

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