SB0663 Enrolled LRB096 06728 MJR 16812 b

1     AN ACT concerning regulation.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Comprehensive Health Insurance Plan Act is
5 amended by changing Sections 7 and 8 as follows:
 
6     (215 ILCS 105/7)  (from Ch. 73, par. 1307)
7     Sec. 7. Eligibility.
8     a. Except as provided in subsection (e) of this Section or
9 in Section 15 of this Act, any person who is either a citizen
10 of the United States or an alien lawfully admitted for
11 permanent residence and who has been for a period of at least
12 180 days and continues to be a resident of this State shall be
13 eligible for Plan coverage under this Section if evidence is
14 provided of:
15         (1) A notice of rejection or refusal to issue
16     substantially similar individual health insurance coverage
17     for health reasons by a health insurance issuer; or
18         (2) A refusal by a health insurance issuer to issue
19     individual health insurance coverage except at a rate
20     exceeding the applicable Plan rate for which the person is
21     responsible.
22     A rejection or refusal by a group health plan or health
23 insurance issuer offering only stop-loss or excess of loss

 

 

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1 insurance or contracts, agreements, or other arrangements for
2 reinsurance coverage with respect to the applicant shall not be
3 sufficient evidence under this subsection.
4     b. The board shall promulgate a list of medical or health
5 conditions for which a person who is either a citizen of the
6 United States or an alien lawfully admitted for permanent
7 residence and a resident of this State would be eligible for
8 Plan coverage without applying for health insurance coverage
9 pursuant to subsection a. of this Section. Persons who can
10 demonstrate the existence or history of any medical or health
11 conditions on the list promulgated by the board shall not be
12 required to provide the evidence specified in subsection a. of
13 this Section. The list shall be effective on the first day of
14 the operation of the Plan and may be amended from time to time
15 as appropriate.
16     c. Family members of the same household who each are
17 covered persons are eligible for optional family coverage under
18 the Plan.
19     d. For persons qualifying for coverage in accordance with
20 Section 7 of this Act, the board shall, if it determines that
21 such appropriations as are made pursuant to Section 12 of this
22 Act are insufficient to allow the board to accept all of the
23 eligible persons which it projects will apply for enrollment
24 under the Plan, limit or close enrollment to ensure that the
25 Plan is not over-subscribed and that it has sufficient
26 resources to meet its obligations to existing enrollees. The

 

 

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1 board shall not limit or close enrollment for federally
2 eligible individuals.
3     e. A person shall not be eligible for coverage under the
4 Plan if:
5         (1) He or she has or obtains other coverage under a
6     group health plan or health insurance coverage
7     substantially similar to or better than a Plan policy as an
8     insured or covered dependent or would be eligible to have
9     that coverage if he or she elected to obtain it. Persons
10     otherwise eligible for Plan coverage may, however, solely
11     for the purpose of having coverage for a pre-existing
12     condition, maintain other coverage only while satisfying
13     any pre-existing condition waiting period under a Plan
14     policy or a subsequent replacement policy of a Plan policy.
15         (1.1) His or her prior coverage under a group health
16     plan or health insurance coverage, provided or arranged by
17     an employer of more than 10 employees was discontinued for
18     any reason without the entire group or plan being
19     discontinued and not replaced, provided he or she remains
20     an employee, or dependent thereof, of the same employer.
21         (2) He or she is a recipient of or is approved to
22     receive medical assistance, except that a person may
23     continue to receive medical assistance through the medical
24     assistance no grant program, but only while satisfying the
25     requirements for a preexisting condition under Section 8,
26     subsection f. of this Act. Payment of premiums pursuant to

 

 

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1     this Act shall be allocable to the person's spenddown for
2     purposes of the medical assistance no grant program, but
3     that person shall not be eligible for any Plan benefits
4     while that person remains eligible for medical assistance.
5     If the person continues to receive or be approved to
6     receive medical assistance through the medical assistance
7     no grant program at or after the time that requirements for
8     a preexisting condition are satisfied, the person shall not
9     be eligible for coverage under the Plan. In that
10     circumstance, coverage under the plan shall terminate as of
11     the expiration of the preexisting condition limitation
12     period. Under all other circumstances, coverage under the
13     Plan shall automatically terminate as of the effective date
14     of any medical assistance.
15         (3) Except as provided in Section 15, the person has
16     previously participated in the Plan and voluntarily
17     terminated Plan coverage, unless 12 months have elapsed
18     since the person's latest voluntary termination of
19     coverage.
20         (4) The person fails to pay the required premium under
21     the covered person's terms of enrollment and
22     participation, in which event the liability of the Plan
23     shall be limited to benefits incurred under the Plan for
24     the time period for which premiums had been paid and the
25     covered person remained eligible for Plan coverage.
26         (5) The Plan (i) until 3 years after the effective date

 

 

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1     of this amendatory Act of the 95th General Assembly has
2     paid a total of $5,000,000 $2,000,000 in benefits on behalf
3     of the covered person or (ii) 3 years or more after the
4     effective date of this amendatory Act of the 95th General
5     Assembly has paid a total of $1,500,000 in benefits on
6     behalf of the covered person.
7         (6) The person is a resident of a public institution.
8         (7) The person's premium is paid for or reimbursed
9     under any government sponsored program or by any government
10     agency or health care provider, except as an otherwise
11     qualifying full-time employee, or dependent of such
12     employee, of a government agency or health care provider
13     or, except when a person's premium is paid by the U.S.
14     Treasury Department pursuant to the federal Trade Act of
15     2002.
16         (8) The person has or later receives other benefits or
17     funds from any settlement, judgement, or award resulting
18     from any accident or injury, regardless of the date of the
19     accident or injury, or any other circumstances creating a
20     legal liability for damages due that person by a third
21     party, whether the settlement, judgment, or award is in the
22     form of a contract, agreement, or trust on behalf of a
23     minor or otherwise and whether the settlement, judgment, or
24     award is payable to the person, his or her dependent,
25     estate, personal representative, or guardian in a lump sum
26     or over time, so long as there continues to be benefits or

 

 

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1     assets remaining from those sources in an amount in excess
2     of $300,000.
3         (9) Within the 5 years prior to the date a person's
4     Plan application is received by the Board, the person's
5     coverage under any health care benefit program as defined
6     in 18 U.S.C. 24, including any public or private plan or
7     contract under which any medical benefit, item, or service
8     is provided, was terminated as a result of any act or
9     practice that constitutes fraud under State or federal law
10     or as a result of an intentional misrepresentation of
11     material fact; or if that person knowingly and willfully
12     obtained or attempted to obtain, or fraudulently aided or
13     attempted to aid any other person in obtaining, any
14     coverage or benefits under the Plan to which that person
15     was not entitled.
16     f. The board or the administrator shall require
17 verification of residency and may require any additional
18 information or documentation, or statements under oath, when
19 necessary to determine residency upon initial application and
20 for the entire term of the policy.
21     g. Coverage shall cease (i) on the date a person is no
22 longer a resident of Illinois, (ii) on the date a person
23 requests coverage to end, (iii) upon the death of the covered
24 person, (iv) on the date State law requires cancellation of the
25 policy, or (v) at the Plan's option, 30 days after the Plan
26 makes any inquiry concerning a person's eligibility or place of

 

 

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1 residence to which the person does not reply.
2     h. Except under the conditions set forth in subsection g of
3 this Section, the coverage of any person who ceases to meet the
4 eligibility requirements of this Section shall be terminated at
5 the end of the current policy period for which the necessary
6 premiums have been paid.
7 (Source: P.A. 94-17, eff. 1-1-06; 94-737, eff. 5-3-06; 95-547,
8 eff. 8-29-07.)
 
9     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
10     Sec. 8. Minimum benefits.
11     a. Availability. The Plan shall offer in a periodically
12 renewable policy major medical expense coverage to every
13 eligible person who is not eligible for Medicare. Major medical
14 expense coverage offered by the Plan shall pay an eligible
15 person's covered expenses, subject to limit on the deductible
16 and coinsurance payments authorized under paragraph (4) of
17 subsection d of this Section, up to a lifetime benefit limit of
18 $5,000,000 $2,000,000 until 3 years after the effective date of
19 this amendatory Act of the 95th General Assembly, and
20 $1,500,000 in benefits 3 years or more after the effective date
21 of this amendatory Act of the 95th General Assembly per covered
22 individual. The maximum limit under this subsection shall not
23 be altered by the Board, and no actuarial equivalent benefit
24 may be substituted by the Board. Any person who otherwise would
25 qualify for coverage under the Plan, but is excluded because he

 

 

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1 or she is eligible for Medicare, shall be eligible for any
2 separate Medicare supplement policy or policies which the Board
3 may offer.
4     b. Outline of benefits. Covered expenses shall be limited
5 to the usual and customary charge, including negotiated fees,
6 in the locality for the following services and articles when
7 prescribed by a physician and determined by the Plan to be
8 medically necessary for the following areas of services,
9 subject to such separate deductibles, co-payments, exclusions,
10 and other limitations on benefits as the Board shall establish
11 and approve, and the other provisions of this Section:
12         (1) Hospital services, except that any services
13     provided by a hospital that is located more than 75 miles
14     outside the State of Illinois shall be covered only for a
15     maximum of 45 days in any calendar year. With respect to
16     covered expenses incurred during any calendar year ending
17     on or after December 31, 1999, inpatient hospitalization of
18     an eligible person for the treatment of mental illness at a
19     hospital located within the State of Illinois shall be
20     subject to the same terms and conditions as for any other
21     illness.
22         (2) Professional services for the diagnosis or
23     treatment of injuries, illnesses or conditions, other than
24     dental and mental and nervous disorders as described in
25     paragraph (17), which are rendered by a physician, or by
26     other licensed professionals at the physician's direction.

 

 

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1     This includes reconstruction of the breast on which a
2     mastectomy was performed; surgery and reconstruction of
3     the other breast to produce a symmetrical appearance; and
4     prostheses and treatment of physical complications at all
5     stages of the mastectomy, including lymphedemas.
6         (2.5) Professional services provided by a physician to
7     children under the age of 16 years for physical
8     examinations and age appropriate immunizations ordered by
9     a physician licensed to practice medicine in all its
10     branches.
11         (3) (Blank).
12         (4) Outpatient prescription drugs that by law require a
13     prescription written by a physician licensed to practice
14     medicine in all its branches subject to such separate
15     deductible, copayment, and other limitations or
16     restrictions as the Board shall approve, including the use
17     of a prescription drug card or any other program, or both.
18         (5) Skilled nursing services of a licensed skilled
19     nursing facility for not more than 120 days during a policy
20     year.
21         (6) Services of a home health agency in accord with a
22     home health care plan, up to a maximum of 270 visits per
23     year.
24         (7) Services of a licensed hospice for not more than
25     180 days during a policy year.
26         (8) Use of radium or other radioactive materials.

 

 

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1         (9) Oxygen.
2         (10) Anesthetics.
3         (11) Orthoses and prostheses other than dental.
4         (12) Rental or purchase in accordance with Board
5     policies or procedures of durable medical equipment, other
6     than eyeglasses or hearing aids, for which there is no
7     personal use in the absence of the condition for which it
8     is prescribed.
9         (13) Diagnostic x-rays and laboratory tests.
10         (14) Oral surgery (i) for excision of partially or
11     completely unerupted impacted teeth when not performed in
12     connection with the routine extraction or repair of teeth;
13     (ii) for excision of tumors or cysts of the jaws, cheeks,
14     lips, tongue, and roof and floor of the mouth; (iii)
15     required for correction of cleft lip and palate and other
16     craniofacial and maxillofacial birth defects; or (iv) for
17     treatment of injuries to natural teeth or a fractured jaw
18     due to an accident.
19         (15) Physical, speech, and functional occupational
20     therapy as medically necessary and provided by appropriate
21     licensed professionals.
22         (16) Emergency and other medically necessary
23     transportation provided by a licensed ambulance service to
24     the nearest health care facility qualified to treat a
25     covered illness, injury, or condition, subject to the
26     provisions of the Emergency Medical Systems (EMS) Act.

 

 

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1         (17) Outpatient services for diagnosis and treatment
2     of mental and nervous disorders provided that a covered
3     person shall be required to make a copayment not to exceed
4     50% and that the Plan's payment shall not exceed such
5     amounts as are established by the Board.
6         (18) Human organ or tissue transplants specified by the
7     Board that are performed at a hospital designated by the
8     Board as a participating transplant center for that
9     specific organ or tissue transplant.
10         (19) Naprapathic services, as appropriate, provided by
11     a licensed naprapathic practitioner.
12     c. Exclusions. Covered expenses of the Plan shall not
13 include the following:
14         (1) Any charge for treatment for cosmetic purposes
15     other than for reconstructive surgery when the service is
16     incidental to or follows surgery resulting from injury,
17     sickness or other diseases of the involved part or surgery
18     for the repair or treatment of a congenital bodily defect
19     to restore normal bodily functions.
20         (2) Any charge for care that is primarily for rest,
21     custodial, educational, or domiciliary purposes.
22         (3) Any charge for services in a private room to the
23     extent it is in excess of the institution's charge for its
24     most common semiprivate room, unless a private room is
25     prescribed as medically necessary by a physician.
26         (4) That part of any charge for room and board or for

 

 

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1     services rendered or articles prescribed by a physician,
2     dentist, or other health care personnel that exceeds the
3     reasonable and customary charge in the locality or for any
4     services or supplies not medically necessary for the
5     diagnosed injury or illness.
6         (5) Any charge for services or articles the provision
7     of which is not within the scope of licensure of the
8     institution or individual providing the services or
9     articles.
10         (6) Any expense incurred prior to the effective date of
11     coverage by the Plan for the person on whose behalf the
12     expense is incurred.
13         (7) Dental care, dental surgery, dental treatment, any
14     other dental procedure involving the teeth or
15     periodontium, or any dental appliances, including crowns,
16     bridges, implants, or partial or complete dentures, except
17     as specifically provided in paragraph (14) of subsection b
18     of this Section.
19         (8) Eyeglasses, contact lenses, hearing aids or their
20     fitting.
21         (9) Illness or injury due to acts of war.
22         (10) Services of blood donors and any fee for failure
23     to replace the first 3 pints of blood provided to a covered
24     person each policy year.
25         (11) Personal supplies or services provided by a
26     hospital or nursing home, or any other nonmedical or

 

 

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1     nonprescribed supply or service.
2         (12) Routine maternity charges for a pregnancy, except
3     where added as optional coverage with payment of an
4     additional premium for pregnancy resulting from conception
5     occurring after the effective date of the optional
6     coverage.
7         (13) (Blank).
8         (14) Any expense or charge for services, drugs, or
9     supplies that are: (i) not provided in accord with
10     generally accepted standards of current medical practice;
11     (ii) for procedures, treatments, equipment, transplants,
12     or implants, any of which are investigational,
13     experimental, or for research purposes; (iii)
14     investigative and not proven safe and effective; or (iv)
15     for, or resulting from, a gender transformation operation.
16         (15) Any expense or charge for routine physical
17     examinations or tests except as provided in item (2.5) of
18     subsection b of this Section.
19         (16) Any expense for which a charge is not made in the
20     absence of insurance or for which there is no legal
21     obligation on the part of the patient to pay.
22         (17) Any expense incurred for benefits provided under
23     the laws of the United States and this State, including
24     Medicare, Medicaid, and other medical assistance, maternal
25     and child health services and any other program that is
26     administered or funded by the Department of Human Services,

 

 

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1     Department of Healthcare and Family Services, or
2     Department of Public Health, military service-connected
3     disability payments, medical services provided for members
4     of the armed forces and their dependents or employees of
5     the armed forces of the United States, and medical services
6     financed on behalf of all citizens by the United States.
7         (18) Any expense or charge for in vitro fertilization,
8     artificial insemination, or any other artificial means
9     used to cause pregnancy.
10         (19) Any expense or charge for oral contraceptives used
11     for birth control or any other temporary birth control
12     measures.
13         (20) Any expense or charge for sterilization or
14     sterilization reversals.
15         (21) Any expense or charge for weight loss programs,
16     exercise equipment, or treatment of obesity, except when
17     certified by a physician as morbid obesity (at least 2
18     times normal body weight).
19         (22) Any expense or charge for acupuncture treatment
20     unless used as an anesthetic agent for a covered surgery.
21         (23) Any expense or charge for or related to organ or
22     tissue transplants other than those performed at a hospital
23     with a Board approved organ transplant program that has
24     been designated by the Board as a preferred or exclusive
25     provider organization for that specific organ or tissue
26     transplant.

 

 

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1         (24) Any expense or charge for procedures, treatments,
2     equipment, or services that are provided in special
3     settings for research purposes or in a controlled
4     environment, are being studied for safety, efficiency, and
5     effectiveness, and are awaiting endorsement by the
6     appropriate national medical speciality college for
7     general use within the medical community.
8     d. Deductibles and coinsurance.
9     The Plan coverage defined in Section 6 shall provide for a
10 choice of deductibles per individual as authorized by the
11 Board. If 2 individual members of the same family household,
12 who are both covered persons under the Plan, satisfy the same
13 applicable deductibles, no other member of that family who is
14 also a covered person under the Plan shall be required to meet
15 any deductibles for the balance of that calendar year. The
16 deductibles must be applied first to the authorized amount of
17 covered expenses incurred by the covered person. A mandatory
18 coinsurance requirement shall be imposed at the rate authorized
19 by the Board in excess of the mandatory deductible, the
20 coinsurance in the aggregate not to exceed such amounts as are
21 authorized by the Board per annum. At its discretion the Board
22 may, however, offer catastrophic coverages or other policies
23 that provide for larger deductibles with or without coinsurance
24 requirements. The deductibles and coinsurance factors may be
25 adjusted annually according to the Medical Component of the
26 Consumer Price Index.

 

 

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1     e. Scope of coverage.
2         (1) In approving any of the benefit plans to be offered
3     by the Plan, the Board shall establish such benefit levels,
4     deductibles, coinsurance factors, exclusions, and
5     limitations as it may deem appropriate and that it believes
6     to be generally reflective of and commensurate with health
7     insurance coverage that is provided in the individual
8     market in this State.
9         (2) The benefit plans approved by the Board may also
10     provide for and employ various cost containment measures
11     and other requirements including, but not limited to,
12     preadmission certification, prior approval, second
13     surgical opinions, concurrent utilization review programs,
14     individual case management, preferred provider
15     organizations, health maintenance organizations, and other
16     cost effective arrangements for paying for covered
17     expenses.
18     f. Preexisting conditions.
19         (1) Except for federally eligible individuals
20     qualifying for Plan coverage under Section 15 of this Act
21     or eligible persons who qualify for the waiver authorized
22     in paragraph (3) of this subsection, plan coverage shall
23     exclude charges or expenses incurred during the first 6
24     months following the effective date of coverage as to any
25     condition for which medical advice, care or treatment was
26     recommended or received during the 6 month period

 

 

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1     immediately preceding the effective date of coverage.
2         (2) (Blank).
3         (3) Waiver: The preexisting condition exclusions as
4     set forth in paragraph (1) of this subsection shall be
5     waived to the extent to which the eligible person (a) has
6     satisfied similar exclusions under any prior individual
7     health insurance policy that was involuntarily terminated
8     because of the insolvency of the issuer of the policy and
9     (b) has applied for Plan coverage within 90 days following
10     the involuntary termination of that individual health
11     insurance coverage.
12         (4) Waiver: The preexisting condition exclusions as
13     set forth in paragraph (1) of this subsection shall be
14     waived to the extent to which the eligible person (a) has
15     satisfied the exclusion under prior Comprehensive Health
16     Insurance Plan coverage that was involuntarily terminated
17     because of meeting a lower lifetime benefit limit and (b)
18     has reapplied for Plan coverage within 90 days following an
19     increase in the lifetime benefit limit set forth in Section
20     8 of this Act.
21     g. Other sources primary; nonduplication of benefits.
22         (1) The Plan shall be the last payor of benefits
23     whenever any other benefit or source of third party payment
24     is available. Subject to the provisions of subsection e of
25     Section 7, benefits otherwise payable under Plan coverage
26     shall be reduced by all amounts paid or payable by Medicare

 

 

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

 

 

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

 

 

SB0663 Enrolled - 20 - LRB096 06728 MJR 16812 b

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

 

 

SB0663 Enrolled - 21 - LRB096 06728 MJR 16812 b

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

 

 

SB0663 Enrolled - 22 - LRB096 06728 MJR 16812 b

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

 

 

SB0663 Enrolled - 23 - LRB096 06728 MJR 16812 b

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

 

 

SB0663 Enrolled - 24 - LRB096 06728 MJR 16812 b

1     appropriate costs. The Plan shall pay its pro rata share of
2     the attorney fees based on the Plan's recovery as it
3     compares to the total judgment. Any reimbursement rights of
4     the Plan shall take priority over all other liens and
5     charges existing under the laws of this State with the
6     exception of any attorney liens filed under the Attorneys
7     Lien Act.
8         (7) The Plan may compromise or settle and release any
9     claim for benefits provided under this Act or waive any
10     claims for benefits, in whole or in part, for the
11     convenience of the Plan or if the Plan determines that
12     collection would result in undue hardship upon the covered
13     person.
14 (Source: P.A. 95-547, eff. 8-29-07; 96-791, eff. 9-25-09.)
 
15     Section 99. Effective date. This Act takes effect upon
16 becoming law.