Sen. Deanna Demuzio

Filed: 3/12/2010

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 663

2     AMENDMENT NO. ______. Amend Senate Bill 663 by replacing
3 everything after the enacting clause with the following:
 
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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1 for the entire term of the policy.
2     g. Coverage shall cease (i) on the date a person is no
3 longer a resident of Illinois, (ii) on the date a person
4 requests coverage to end, (iii) upon the death of the covered
5 person, (iv) on the date State law requires cancellation of the
6 policy, or (v) at the Plan's option, 30 days after the Plan
7 makes any inquiry concerning a person's eligibility or place of
8 residence to which the person does not reply.
9     h. Except under the conditions set forth in subsection g of
10 this Section, the coverage of any person who ceases to meet the
11 eligibility requirements of this Section shall be terminated at
12 the end of the current policy period for which the necessary
13 premiums have been paid.
14 (Source: P.A. 94-17, eff. 1-1-06; 94-737, eff. 5-3-06; 95-547,
15 eff. 8-29-07.)
 
16     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
17     Sec. 8. Minimum benefits.
18     a. Availability. The Plan shall offer in a periodically
19 renewable policy major medical expense coverage to every
20 eligible person who is not eligible for Medicare. Major medical
21 expense coverage offered by the Plan shall pay an eligible
22 person's covered expenses, subject to limit on the deductible
23 and coinsurance payments authorized under paragraph (4) of
24 subsection d of this Section, up to a lifetime benefit limit of
25 $5,000,000 $2,000,000 until 3 years after the effective date of

 

 

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

 

 

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1     subject to the same terms and conditions as for any other
2     illness.
3         (2) Professional services for the diagnosis or
4     treatment of injuries, illnesses or conditions, other than
5     dental and mental and nervous disorders as described in
6     paragraph (17), which are rendered by a physician, or by
7     other licensed professionals at the physician's direction.
8     This includes reconstruction of the breast on which a
9     mastectomy was performed; surgery and reconstruction of
10     the other breast to produce a symmetrical appearance; and
11     prostheses and treatment of physical complications at all
12     stages of the mastectomy, including lymphedemas.
13         (2.5) Professional services provided by a physician to
14     children under the age of 16 years for physical
15     examinations and age appropriate immunizations ordered by
16     a physician licensed to practice medicine in all its
17     branches.
18         (3) (Blank).
19         (4) Outpatient prescription drugs that by law require a
20     prescription written by a physician licensed to practice
21     medicine in all its branches subject to such separate
22     deductible, copayment, and other limitations or
23     restrictions as the Board shall approve, including the use
24     of a prescription drug card or any other program, or both.
25         (5) Skilled nursing services of a licensed skilled
26     nursing facility for not more than 120 days during a policy

 

 

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

 

 

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

 

 

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1         (2) Any charge for care that is primarily for rest,
2     custodial, educational, or domiciliary purposes.
3         (3) Any charge for services in a private room to the
4     extent it is in excess of the institution's charge for its
5     most common semiprivate room, unless a private room is
6     prescribed as medically necessary by a physician.
7         (4) That part of any charge for room and board or for
8     services rendered or articles prescribed by a physician,
9     dentist, or other health care personnel that exceeds the
10     reasonable and customary charge in the locality or for any
11     services or supplies not medically necessary for the
12     diagnosed injury or illness.
13         (5) Any charge for services or articles the provision
14     of which is not within the scope of licensure of the
15     institution or individual providing the services or
16     articles.
17         (6) Any expense incurred prior to the effective date of
18     coverage by the Plan for the person on whose behalf the
19     expense is incurred.
20         (7) Dental care, dental surgery, dental treatment, any
21     other dental procedure involving the teeth or
22     periodontium, or any dental appliances, including crowns,
23     bridges, implants, or partial or complete dentures, except
24     as specifically provided in paragraph (14) of subsection b
25     of this Section.
26         (8) Eyeglasses, contact lenses, hearing aids or their

 

 

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1     fitting.
2         (9) Illness or injury due to acts of war.
3         (10) Services of blood donors and any fee for failure
4     to replace the first 3 pints of blood provided to a covered
5     person each policy year.
6         (11) Personal supplies or services provided by a
7     hospital or nursing home, or any other nonmedical or
8     nonprescribed supply or service.
9         (12) Routine maternity charges for a pregnancy, except
10     where added as optional coverage with payment of an
11     additional premium for pregnancy resulting from conception
12     occurring after the effective date of the optional
13     coverage.
14         (13) (Blank).
15         (14) Any expense or charge for services, drugs, or
16     supplies that are: (i) not provided in accord with
17     generally accepted standards of current medical practice;
18     (ii) for procedures, treatments, equipment, transplants,
19     or implants, any of which are investigational,
20     experimental, or for research purposes; (iii)
21     investigative and not proven safe and effective; or (iv)
22     for, or resulting from, a gender transformation operation.
23         (15) Any expense or charge for routine physical
24     examinations or tests except as provided in item (2.5) of
25     subsection b of this Section.
26         (16) Any expense for which a charge is not made in the

 

 

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1     absence of insurance or for which there is no legal
2     obligation on the part of the patient to pay.
3         (17) Any expense incurred for benefits provided under
4     the laws of the United States and this State, including
5     Medicare, Medicaid, and other medical assistance, maternal
6     and child health services and any other program that is
7     administered or funded by the Department of Human Services,
8     Department of Healthcare and Family Services, or
9     Department of Public Health, military service-connected
10     disability payments, medical services provided for members
11     of the armed forces and their dependents or employees of
12     the armed forces of the United States, and medical services
13     financed on behalf of all citizens by the United States.
14         (18) Any expense or charge for in vitro fertilization,
15     artificial insemination, or any other artificial means
16     used to cause pregnancy.
17         (19) Any expense or charge for oral contraceptives used
18     for birth control or any other temporary birth control
19     measures.
20         (20) Any expense or charge for sterilization or
21     sterilization reversals.
22         (21) Any expense or charge for weight loss programs,
23     exercise equipment, or treatment of obesity, except when
24     certified by a physician as morbid obesity (at least 2
25     times normal body weight).
26         (22) Any expense or charge for acupuncture treatment

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

09600SB0663sam001 - 21 - LRB096 06728 RPM 38845 a

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

 

 

09600SB0663sam001 - 22 - LRB096 06728 RPM 38845 a

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

 

 

09600SB0663sam001 - 23 - LRB096 06728 RPM 38845 a

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

 

 

09600SB0663sam001 - 24 - LRB096 06728 RPM 38845 a

1     compares to the total judgment. Any reimbursement rights of
2     the Plan shall take priority over all other liens and
3     charges existing under the laws of this State with the
4     exception of any attorney liens filed under the Attorneys
5     Lien Act.
6         (7) The Plan may compromise or settle and release any
7     claim for benefits provided under this Act or waive any
8     claims for benefits, in whole or in part, for the
9     convenience of the Plan or if the Plan determines that
10     collection would result in undue hardship upon the covered
11     person.
12 (Source: P.A. 95-547, eff. 8-29-07; 96-791, eff. 9-25-09.)".