Rep. Karen May

Filed: 5/23/2007

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 144

2     AMENDMENT NO. ______. Amend Senate Bill 144, AS AMENDED, by
3 replacing everything after the enacting clause with the
4 following:
 
5     "Section 5. The Comprehensive Health Insurance Plan Act is
6 amended by changing Sections 7 and 8 as follows:
 
7     (215 ILCS 105/7)  (from Ch. 73, par. 1307)
8     Sec. 7. Eligibility.
9     a. Except as provided in subsection (e) of this Section or
10 in Section 15 of this Act, any person who is either a citizen
11 of the United States or an alien lawfully admitted for
12 permanent residence and who has been for a period of at least
13 180 days and continues to be a resident of this State shall be
14 eligible for Plan coverage under this Section if evidence is
15 provided of:
16         (1) A notice of rejection or refusal to issue

 

 

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1     substantially similar individual health insurance coverage
2     for health reasons by a health insurance issuer; or
3         (2) A refusal by a health insurance issuer to issue
4     individual health insurance coverage except at a rate
5     exceeding the applicable Plan rate for which the person is
6     responsible.
7     A rejection or refusal by a group health plan or health
8 insurance issuer offering only stop-loss or excess of loss
9 insurance or contracts, agreements, or other arrangements for
10 reinsurance coverage with respect to the applicant shall not be
11 sufficient evidence under this subsection.
12     b. The board shall promulgate a list of medical or health
13 conditions for which a person who is either a citizen of the
14 United States or an alien lawfully admitted for permanent
15 residence and a resident of this State would be eligible for
16 Plan coverage without applying for health insurance coverage
17 pursuant to subsection a. of this Section. Persons who can
18 demonstrate the existence or history of any medical or health
19 conditions on the list promulgated by the board shall not be
20 required to provide the evidence specified in subsection a. of
21 this Section. The list shall be effective on the first day of
22 the operation of the Plan and may be amended from time to time
23 as appropriate.
24     c. Family members of the same household who each are
25 covered persons are eligible for optional family coverage under
26 the Plan.

 

 

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1     d. For persons qualifying for coverage in accordance with
2 Section 7 of this Act, the board shall, if it determines that
3 such appropriations as are made pursuant to Section 12 of this
4 Act are insufficient to allow the board to accept all of the
5 eligible persons which it projects will apply for enrollment
6 under the Plan, limit or close enrollment to ensure that the
7 Plan is not over-subscribed and that it has sufficient
8 resources to meet its obligations to existing enrollees. The
9 board shall not limit or close enrollment for federally
10 eligible individuals.
11     e. A person shall not be eligible for coverage under the
12 Plan if:
13         (1) He or she has or obtains other coverage under a
14     group health plan or health insurance coverage
15     substantially similar to or better than a Plan policy as an
16     insured or covered dependent or would be eligible to have
17     that coverage if he or she elected to obtain it. Persons
18     otherwise eligible for Plan coverage may, however, solely
19     for the purpose of having coverage for a pre-existing
20     condition, maintain other coverage only while satisfying
21     any pre-existing condition waiting period under a Plan
22     policy or a subsequent replacement policy of a Plan policy.
23         (1.1) His or her prior coverage under a group health
24     plan or health insurance coverage, provided or arranged by
25     an employer of more than 10 employees was discontinued for
26     any reason without the entire group or plan being

 

 

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1     discontinued and not replaced, provided he or she remains
2     an employee, or dependent thereof, of the same employer.
3         (2) He or she is a recipient of or is approved to
4     receive medical assistance, except that a person may
5     continue to receive medical assistance through the medical
6     assistance no grant program, but only while satisfying the
7     requirements for a preexisting condition under Section 8,
8     subsection f. of this Act. Payment of premiums pursuant to
9     this Act shall be allocable to the person's spenddown for
10     purposes of the medical assistance no grant program, but
11     that person shall not be eligible for any Plan benefits
12     while that person remains eligible for medical assistance.
13     If the person continues to receive or be approved to
14     receive medical assistance through the medical assistance
15     no grant program at or after the time that requirements for
16     a preexisting condition are satisfied, the person shall not
17     be eligible for coverage under the Plan. In that
18     circumstance, coverage under the plan shall terminate as of
19     the expiration of the preexisting condition limitation
20     period. Under all other circumstances, coverage under the
21     Plan shall automatically terminate as of the effective date
22     of any medical assistance.
23         (3) Except as provided in Section 15, the person has
24     previously participated in the Plan and voluntarily
25     terminated Plan coverage, unless 12 months have elapsed
26     since the person's latest voluntary termination of

 

 

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1     coverage.
2         (4) The person fails to pay the required premium under
3     the covered person's terms of enrollment and
4     participation, in which event the liability of the Plan
5     shall be limited to benefits incurred under the Plan for
6     the time period for which premiums had been paid and the
7     covered person remained eligible for Plan coverage.
8         (5) The Plan (i) until 3 years after the effective date
9     of this amendatory Act of the 95th General Assembly has
10     paid a total of $2,000,000 $1,500,000 in benefits on behalf
11     of the covered person or (ii) 3 years or more after the
12     effective date of this amendatory Act of the 95th General
13     Assembly has paid a total of $1,500,000 in benefits on
14     behalf of the covered person.
15         (6) The person is a resident of a public institution.
16         (7) The person's premium is paid for or reimbursed
17     under any government sponsored program or by any government
18     agency or health care provider, except as an otherwise
19     qualifying full-time employee, or dependent of such
20     employee, of a government agency or health care provider
21     or, except when a person's premium is paid by the U.S.
22     Treasury Department pursuant to the federal Trade Act of
23     2002.
24         (8) The person has or later receives other benefits or
25     funds from any settlement, judgement, or award resulting
26     from any accident or injury, regardless of the date of the

 

 

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1     accident or injury, or any other circumstances creating a
2     legal liability for damages due that person by a third
3     party, whether the settlement, judgment, or award is in the
4     form of a contract, agreement, or trust on behalf of a
5     minor or otherwise and whether the settlement, judgment, or
6     award is payable to the person, his or her dependent,
7     estate, personal representative, or guardian in a lump sum
8     or over time, so long as there continues to be benefits or
9     assets remaining from those sources in an amount in excess
10     of $300,000.
11         (9) Within the 5 years prior to the date a person's
12     Plan application is received by the Board, the person's
13     coverage under any health care benefit program as defined
14     in 18 U.S.C. 24, including any public or private plan or
15     contract under which any medical benefit, item, or service
16     is provided, was terminated as a result of any act or
17     practice that constitutes fraud under State or federal law
18     or as a result of an intentional misrepresentation of
19     material fact; or if that person knowingly and willfully
20     obtained or attempted to obtain, or fraudulently aided or
21     attempted to aid any other person in obtaining, any
22     coverage or benefits under the Plan to which that person
23     was not entitled.
24     f. The board or the administrator shall require
25 verification of residency and may require any additional
26 information or documentation, or statements under oath, when

 

 

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1 necessary to determine residency upon initial application and
2 for the entire term of the policy.
3     g. Coverage shall cease (i) on the date a person is no
4 longer a resident of Illinois, (ii) on the date a person
5 requests coverage to end, (iii) upon the death of the covered
6 person, (iv) on the date State law requires cancellation of the
7 policy, or (v) at the Plan's option, 30 days after the Plan
8 makes any inquiry concerning a person's eligibility or place of
9 residence to which the person does not reply.
10     h. Except under the conditions set forth in subsection g of
11 this Section, the coverage of any person who ceases to meet the
12 eligibility requirements of this Section shall be terminated at
13 the end of the current policy period for which the necessary
14 premiums have been paid.
15 (Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03; 94-17,
16 eff. 1-1-06; 94-737, eff. 5-3-06.)
 
17     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
18     Sec. 8. Minimum benefits.
19     a. Availability. The Plan shall offer in an annually
20 renewable policy major medical expense coverage to every
21 eligible person who is not eligible for Medicare. Major medical
22 expense coverage offered by the Plan shall pay an eligible
23 person's covered expenses, subject to limit on the deductible
24 and coinsurance payments authorized under paragraph (4) of
25 subsection d of this Section, up to a lifetime benefit limit of

 

 

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1 $2,000,000 until 3 years after the effective date of this
2 amendatory Act of the 95th General Assembly, and $1,500,000 in
3 benefits 3 years or more after the effective date of this
4 amendatory Act of the 95th General Assembly per covered
5 individual. The maximum limit under this subsection shall not
6 be altered by the Board, and no actuarial equivalent benefit
7 may be substituted by the Board. Any person who otherwise would
8 qualify for coverage under the Plan, but is excluded because he
9 or she is eligible for Medicare, shall be eligible for any
10 separate Medicare supplement policy or policies which the Board
11 may offer.
12     b. Outline of benefits. Covered expenses shall be limited
13 to the usual and customary charge, including negotiated fees,
14 in the locality for the following services and articles when
15 prescribed by a physician and determined by the Plan to be
16 medically necessary for the following areas of services,
17 subject to such separate deductibles, co-payments, exclusions,
18 and other limitations on benefits as the Board shall establish
19 and approve, and the other provisions of this Section:
20         (1) Hospital services, except that any services
21     provided by a hospital that is located more than 75 miles
22     outside the State of Illinois shall be covered only for a
23     maximum of 45 days in any calendar year. With respect to
24     covered expenses incurred during any calendar year ending
25     on or after December 31, 1999, inpatient hospitalization of
26     an eligible person for the treatment of mental illness at a

 

 

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1     hospital located within the State of Illinois shall be
2     subject to the same terms and conditions as for any other
3     illness.
4         (2) Professional services for the diagnosis or
5     treatment of injuries, illnesses or conditions, other than
6     dental and mental and nervous disorders as described in
7     paragraph (17), which are rendered by a physician, or by
8     other licensed professionals at the physician's direction.
9     This includes reconstruction of the breast on which a
10     mastectomy was performed; surgery and reconstruction of
11     the other breast to produce a symmetrical appearance; and
12     prostheses and treatment of physical complications at all
13     stages of the mastectomy, including lymphedemas.
14         (2.5) Professional services provided by a physician to
15     children under the age of 16 years for physical
16     examinations and age appropriate immunizations ordered by
17     a physician licensed to practice medicine in all its
18     branches.
19         (3) (Blank).
20         (4) Outpatient prescription drugs that by law require a
21     prescription written by a physician licensed to practice
22     medicine in all its branches subject to such separate
23     deductible, copayment, and other limitations or
24     restrictions as the Board shall approve, including the use
25     of a prescription drug card or any other program, or both.
26         (5) Skilled nursing services of a licensed skilled

 

 

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1     nursing facility for not more than 120 days during a policy
2     year.
3         (6) Services of a home health agency in accord with a
4     home health care plan, up to a maximum of 270 visits per
5     year.
6         (7) Services of a licensed hospice for not more than
7     180 days during a policy year.
8         (8) Use of radium or other radioactive materials.
9         (9) Oxygen.
10         (10) Anesthetics.
11         (11) Orthoses and prostheses other than dental.
12         (12) Rental or purchase in accordance with Board
13     policies or procedures of durable medical equipment, other
14     than eyeglasses or hearing aids, for which there is no
15     personal use in the absence of the condition for which it
16     is prescribed.
17         (13) Diagnostic x-rays and laboratory tests.
18         (14) Oral surgery (i) for excision of partially or
19     completely unerupted impacted teeth when not performed in
20     connection with the routine extraction or repair of teeth;
21     (ii) for excision of tumors or cysts of the jaws, cheeks,
22     lips, tongue, and roof and floor of the mouth; (iii)
23     required for correction of cleft lip and palate and other
24     craniofacial and maxillofacial birth defects; or (iv) for
25     treatment of injuries to natural teeth or a fractured jaw
26     due to an accident.

 

 

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1         (15) Physical, speech, and functional occupational
2     therapy as medically necessary and provided by appropriate
3     licensed professionals.
4         (16) Emergency and other medically necessary
5     transportation provided by a licensed ambulance service to
6     the nearest health care facility qualified to treat a
7     covered illness, injury, or condition, subject to the
8     provisions of the Emergency Medical Systems (EMS) Act.
9         (17) Outpatient services for diagnosis and treatment
10     of mental and nervous disorders provided that a covered
11     person shall be required to make a copayment not to exceed
12     50% and that the Plan's payment shall not exceed such
13     amounts as are established by the Board.
14         (18) Human organ or tissue transplants specified by the
15     Board that are performed at a hospital designated by the
16     Board as a participating transplant center for that
17     specific organ or tissue transplant.
18         (19) Naprapathic services, as appropriate, provided by
19     a licensed naprapathic practitioner.
20         (20) Coverage for benefits as required under Sections
21     356g, 356u, 356x, and 356z.4 of the Illinois Insurance
22     Code.
23     c. Exclusions. Covered expenses of the Plan shall not
24 include the following:
25         (1) Any charge for treatment for cosmetic purposes
26     other than for reconstructive surgery when the service is

 

 

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1     incidental to or follows surgery resulting from injury,
2     sickness or other diseases of the involved part or surgery
3     for the repair or treatment of a congenital bodily defect
4     to restore normal bodily functions.
5         (2) Any charge for care that is primarily for rest,
6     custodial, educational, or domiciliary purposes.
7         (3) Any charge for services in a private room to the
8     extent it is in excess of the institution's charge for its
9     most common semiprivate room, unless a private room is
10     prescribed as medically necessary by a physician.
11         (4) That part of any charge for room and board or for
12     services rendered or articles prescribed by a physician,
13     dentist, or other health care personnel that exceeds the
14     reasonable and customary charge in the locality or for any
15     services or supplies not medically necessary for the
16     diagnosed injury or illness.
17         (5) Any charge for services or articles the provision
18     of which is not within the scope of licensure of the
19     institution or individual providing the services or
20     articles.
21         (6) Any expense incurred prior to the effective date of
22     coverage by the Plan for the person on whose behalf the
23     expense is incurred.
24         (7) Dental care, dental surgery, dental treatment, any
25     other dental procedure involving the teeth or
26     periodontium, or any dental appliances, including crowns,

 

 

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1     bridges, implants, or partial or complete dentures, except
2     as specifically provided in paragraph (14) of subsection b
3     of this Section.
4         (8) Eyeglasses, contact lenses, hearing aids or their
5     fitting.
6         (9) Illness or injury due to acts of war.
7         (10) Services of blood donors and any fee for failure
8     to replace the first 3 pints of blood provided to a covered
9     person each policy year.
10         (11) Personal supplies or services provided by a
11     hospital or nursing home, or any other nonmedical or
12     nonprescribed supply or service.
13         (12) Routine maternity charges for a pregnancy, except
14     where added as optional coverage with payment of an
15     additional premium for pregnancy resulting from conception
16     occurring after the effective date of the optional
17     coverage.
18         (13) (Blank).
19         (14) Any expense or charge for services, drugs, or
20     supplies that are: (i) not provided in accord with
21     generally accepted standards of current medical practice;
22     (ii) for procedures, treatments, equipment, transplants,
23     or implants, any of which are investigational,
24     experimental, or for research purposes; (iii)
25     investigative and not proven safe and effective; or (iv)
26     for, or resulting from, a gender transformation operation.

 

 

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1         (15) Any expense or charge for routine physical
2     examinations or tests except as provided in items item
3     (2.5) and (20) of subsection b of this Section.
4         (16) Any expense for which a charge is not made in the
5     absence of insurance or for which there is no legal
6     obligation on the part of the patient to pay.
7         (17) Any expense incurred for benefits provided under
8     the laws of the United States and this State, including
9     Medicare, Medicaid, and other medical assistance, maternal
10     and child health services and any other program that is
11     administered or funded by the Department of Human Services,
12     Department of Healthcare and Family Services, or
13     Department of Public Health, military service-connected
14     disability payments, medical services provided for members
15     of the armed forces and their dependents or employees of
16     the armed forces of the United States, and medical services
17     financed on behalf of all citizens by the United States.
18         (18) Any expense or charge for in vitro fertilization,
19     artificial insemination, or any other artificial means
20     used to cause pregnancy.
21         (19) Blank. Any expense or charge for oral
22     contraceptives used for birth control or any other
23     temporary birth control measures.
24         (20) Any expense or charge for sterilization or
25     sterilization reversals.
26         (21) Any expense or charge for weight loss programs,

 

 

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1     exercise equipment, or treatment of obesity, except when
2     certified by a physician as morbid obesity (at least 2
3     times normal body weight).
4         (22) Any expense or charge for acupuncture treatment
5     unless used as an anesthetic agent for a covered surgery.
6         (23) Any expense or charge for or related to organ or
7     tissue transplants other than those performed at a hospital
8     with a Board approved organ transplant program that has
9     been designated by the Board as a preferred or exclusive
10     provider organization for that specific organ or tissue
11     transplant.
12         (24) Any expense or charge for procedures, treatments,
13     equipment, or services that are provided in special
14     settings for research purposes or in a controlled
15     environment, are being studied for safety, efficiency, and
16     effectiveness, and are awaiting endorsement by the
17     appropriate national medical speciality college for
18     general use within the medical community.
19     d. Deductibles and coinsurance.
20     The Plan coverage defined in Section 6 shall provide for a
21 choice of deductibles per individual as authorized by the
22 Board. If 2 individual members of the same family household,
23 who are both covered persons under the Plan, satisfy the same
24 applicable deductibles, no other member of that family who is
25 also a covered person under the Plan shall be required to meet
26 any deductibles for the balance of that calendar year. The

 

 

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1 deductibles must be applied first to the authorized amount of
2 covered expenses incurred by the covered person. A mandatory
3 coinsurance requirement shall be imposed at the rate authorized
4 by the Board in excess of the mandatory deductible, the
5 coinsurance in the aggregate not to exceed such amounts as are
6 authorized by the Board per annum. At its discretion the Board
7 may, however, offer catastrophic coverages or other policies
8 that provide for larger deductibles with or without coinsurance
9 requirements. The deductibles and coinsurance factors may be
10 adjusted annually according to the Medical Component of the
11 Consumer Price Index.
12     e. Scope of coverage.
13         (1) In approving any of the benefit plans to be offered
14     by the Plan, the Board shall establish such benefit levels,
15     deductibles, coinsurance factors, exclusions, and
16     limitations as it may deem appropriate and that it believes
17     to be generally reflective of and commensurate with health
18     insurance coverage that is provided in the individual
19     market in this State.
20         (2) The benefit plans approved by the Board may also
21     provide for and employ various cost containment measures
22     and other requirements including, but not limited to,
23     preadmission certification, prior approval, second
24     surgical opinions, concurrent utilization review programs,
25     individual case management, preferred provider
26     organizations, health maintenance organizations, and other

 

 

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1     cost effective arrangements for paying for covered
2     expenses.
3     f. Preexisting conditions.
4         (1) Except for federally eligible individuals
5     qualifying for Plan coverage under Section 15 of this Act
6     or eligible persons who qualify for the waiver authorized
7     in paragraph (3) of this subsection, plan coverage shall
8     exclude charges or expenses incurred during the first 6
9     months following the effective date of coverage as to any
10     condition for which medical advice, care or treatment was
11     recommended or received during the 6 month period
12     immediately preceding the effective date of coverage.
13         (2) (Blank).
14         (3) Waiver: The preexisting condition exclusions as
15     set forth in paragraph (1) of this subsection shall be
16     waived to the extent to which the eligible person (a) has
17     satisfied similar exclusions under any prior individual
18     health insurance policy that was involuntarily terminated
19     because of the insolvency of the issuer of the policy and
20     (b) has applied for Plan coverage within 90 days following
21     the involuntary termination of that individual health
22     insurance coverage.
23     g. Other sources primary; nonduplication of benefits.
24         (1) The Plan shall be the last payor of benefits
25     whenever any other benefit or source of third party payment
26     is available. Subject to the provisions of subsection e of

 

 

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1     Section 7, benefits otherwise payable under Plan coverage
2     shall be reduced by all amounts paid or payable by Medicare
3     or any other government program or through any health
4     insurance coverage or group health plan, whether by
5     insurance, reimbursement, or otherwise, or through any
6     third party liability, settlement, judgment, or award,
7     regardless of the date of the settlement, judgment, or
8     award, whether the settlement, judgment, or award is in the
9     form of a contract, agreement, or trust on behalf of a
10     minor or otherwise and whether the settlement, judgment, or
11     award is payable to the covered person, his or her
12     dependent, estate, personal representative, or guardian in
13     a lump sum or over time, and by all hospital or medical
14     expense benefits paid or payable under any worker's
15     compensation coverage, automobile medical payment, or
16     liability insurance, whether provided on the basis of fault
17     or nonfault, and by any hospital or medical benefits paid
18     or payable under or provided pursuant to any State or
19     federal law or program.
20         (2) The Plan shall have a cause of action against any
21     covered person or any other person or entity for the
22     recovery of any amount paid to the extent the amount was
23     for treatment, services, or supplies not covered in this
24     Section or in excess of benefits as set forth in this
25     Section.
26         (3) Whenever benefits are due from the Plan because of

 

 

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1     sickness or an injury to a covered person resulting from a
2     third party's wrongful act or negligence and the covered
3     person has recovered or may recover damages from a third
4     party or its insurer, the Plan shall have the right to
5     reduce benefits or to refuse to pay benefits that otherwise
6     may be payable by the amount of damages that the covered
7     person has recovered or may recover regardless of the date
8     of the sickness or injury or the date of any settlement,
9     judgment, or award resulting from that sickness or injury.
10         During the pendency of any action or claim that is
11     brought by or on behalf of a covered person against a third
12     party or its insurer, any benefits that would otherwise be
13     payable except for the provisions of this paragraph (3)
14     shall be paid if payment by or for the third party has not
15     yet been made and the covered person or, if incapable, that
16     person's legal representative agrees in writing to pay back
17     promptly the benefits paid as a result of the sickness or
18     injury to the extent of any future payments made by or for
19     the third party for the sickness or injury. This agreement
20     is to apply whether or not liability for the payments is
21     established or admitted by the third party or whether those
22     payments are itemized.
23         Any amounts due the plan to repay benefits may be
24     deducted from other benefits payable by the Plan after
25     payments by or for the third party are made.
26         (4) Benefits due from the Plan may be reduced or

 

 

09500SB0144ham003 - 20 - LRB095 04988 KBJ 36802 a

1     refused as an offset against any amount otherwise
2     recoverable under this Section.
3     h. Right of subrogation; recoveries.
4         (1) Whenever the Plan has paid benefits because of
5     sickness or an injury to any covered person resulting from
6     a third party's wrongful act or negligence, or for which an
7     insurer is liable in accordance with the provisions of any
8     policy of insurance, and the covered person has recovered
9     or may recover damages from a third party that is liable
10     for the damages, the Plan shall have the right to recover
11     the benefits it paid from any amounts that the covered
12     person has received or may receive regardless of the date
13     of the sickness or injury or the date of any settlement,
14     judgment, or award resulting from that sickness or injury.
15     The Plan shall be subrogated to any right of recovery the
16     covered person may have under the terms of any private or
17     public health care coverage or liability coverage,
18     including coverage under the Workers' Compensation Act or
19     the Workers' Occupational Diseases Act, without the
20     necessity of assignment of claim or other authorization to
21     secure the right of recovery. To enforce its subrogation
22     right, the Plan may (i) intervene or join in an action or
23     proceeding brought by the covered person or his personal
24     representative, including his guardian, conservator,
25     estate, dependents, or survivors, against any third party
26     or the third party's insurer that may be liable or (ii)

 

 

09500SB0144ham003 - 21 - LRB095 04988 KBJ 36802 a

1     institute and prosecute legal proceedings against any
2     third party or the third party's insurer that may be liable
3     for the sickness or injury in an appropriate court either
4     in the name of the Plan or in the name of the covered
5     person or his personal representative, including his
6     guardian, conservator, estate, dependents, or survivors.
7         (2) If any action or claim is brought by or on behalf
8     of a covered person against a third party or the third
9     party's insurer, the covered person or his personal
10     representative, including his guardian, conservator,
11     estate, dependents, or survivors, shall notify the Plan by
12     personal service or registered mail of the action or claim
13     and of the name of the court in which the action or claim
14     is brought, filing proof thereof in the action or claim.
15     The Plan may, at any time thereafter, join in the action or
16     claim upon its motion so that all orders of court after
17     hearing and judgment shall be made for its protection. No
18     release or settlement of a claim for damages and no
19     satisfaction of judgment in the action shall be valid
20     without the written consent of the Plan to the extent of
21     its interest in the settlement or judgment and of the
22     covered person or his personal representative.
23         (3) In the event that the covered person or his
24     personal representative fails to institute a proceeding
25     against any appropriate third party before the fifth month
26     before the action would be barred, the Plan may, in its own

 

 

09500SB0144ham003 - 22 - LRB095 04988 KBJ 36802 a

1     name or in the name of the covered person or personal
2     representative, commence a proceeding against any
3     appropriate third party for the recovery of damages on
4     account of any sickness, injury, or death to the covered
5     person. The covered person shall cooperate in doing what is
6     reasonably necessary to assist the Plan in any recovery and
7     shall not take any action that would prejudice the Plan's
8     right to recovery. The Plan shall pay to the covered person
9     or his personal representative all sums collected from any
10     third party by judgment or otherwise in excess of amounts
11     paid in benefits under the Plan and amounts paid or to be
12     paid as costs, attorneys fees, and reasonable expenses
13     incurred by the Plan in making the collection or enforcing
14     the judgment.
15         (4) In the event that a covered person or his personal
16     representative, including his guardian, conservator,
17     estate, dependents, or survivors, recovers damages from a
18     third party for sickness or injury caused to the covered
19     person, the covered person or the personal representative
20     shall pay to the Plan from the damages recovered the amount
21     of benefits paid or to be paid on behalf of the covered
22     person.
23         (5) When the action or claim is brought by the covered
24     person alone and the covered person incurs a personal
25     liability to pay attorney's fees and costs of litigation,
26     the Plan's claim for reimbursement of the benefits provided

 

 

09500SB0144ham003 - 23 - LRB095 04988 KBJ 36802 a

1     to the covered person shall be the full amount of benefits
2     paid to or on behalf of the covered person under this Act
3     less a pro rata share that represents the Plan's reasonable
4     share of attorney's fees paid by the covered person and
5     that portion of the cost of litigation expenses determined
6     by multiplying by the ratio of the full amount of the
7     expenditures to the full amount of the judgement, award, or
8     settlement.
9         (6) In the event of judgment or award in a suit or
10     claim against a third party or insurer, the court shall
11     first order paid from any judgement or award the reasonable
12     litigation expenses incurred in preparation and
13     prosecution of the action or claim, together with
14     reasonable attorney's fees. After payment of those
15     expenses and attorney's fees, the court shall apply out of
16     the balance of the judgment or award an amount sufficient
17     to reimburse the Plan the full amount of benefits paid on
18     behalf of the covered person under this Act, provided the
19     court may reduce and apportion the Plan's portion of the
20     judgement proportionate to the recovery of the covered
21     person. The burden of producing evidence sufficient to
22     support the exercise by the court of its discretion to
23     reduce the amount of a proven charge sought to be enforced
24     against the recovery shall rest with the party seeking the
25     reduction. The court may consider the nature and extent of
26     the injury, economic and non-economic loss, settlement

 

 

09500SB0144ham003 - 24 - LRB095 04988 KBJ 36802 a

1     offers, comparative negligence as it applies to the case at
2     hand, hospital costs, physician costs, and all other
3     appropriate costs. The Plan shall pay its pro rata share of
4     the attorney fees based on the Plan's recovery as it
5     compares to the total judgment. Any reimbursement rights of
6     the Plan shall take priority over all other liens and
7     charges existing under the laws of this State with the
8     exception of any attorney liens filed under the Attorneys
9     Lien Act.
10         (7) The Plan may compromise or settle and release any
11     claim for benefits provided under this Act or waive any
12     claims for benefits, in whole or in part, for the
13     convenience of the Plan or if the Plan determines that
14     collection would result in undue hardship upon the covered
15     person.
16 (Source: P.A. 94-737, eff. 5-3-06.)
 
17     Section 99. Effective date. This Act takes effect upon
18 becoming law.".