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093_HB3622
LRB093 07142 JLS 07297 b
1 AN ACT relating to insurance.
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
5 is 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
9 or in Section 15 of this Act, any person who is either a
10 citizen of the United States or an alien lawfully admitted
11 for permanent residence and who has been for a period of at
12 least 180 days and continues to be a resident of this State
13 shall be eligible for Plan coverage under this Section if
14 evidence is provided of:
15 (1) A notice of rejection or refusal to issue
16 substantially similar individual health insurance
17 coverage for health reasons by a health insurance issuer;
18 or
19 (2) A refusal by a health insurance issuer to issue
20 individual health insurance coverage except at a rate
21 exceeding the applicable Plan rate for which the person
22 is responsible.
23 A rejection or refusal by a group health plan or health
24 insurance issuer offering only stop-loss or excess of loss
25 insurance or contracts, agreements, or other arrangements for
26 reinsurance coverage with respect to the applicant shall not
27 be sufficient evidence under this subsection.
28 b. The board shall promulgate a list of medical or
29 health conditions for which a person who is either a citizen
30 of the United States or an alien lawfully admitted for
31 permanent residence and a resident of this State would be
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1 eligible for Plan coverage without applying for health
2 insurance coverage pursuant to subsection a. of this Section.
3 Persons who can demonstrate the existence or history of any
4 medical or health conditions on the list promulgated by the
5 board shall not be required to provide the evidence specified
6 in subsection a. of this Section. The list shall be
7 effective on the first day of the operation of the Plan and
8 may be amended from time to time as appropriate.
9 c. Family members of the same household who each are
10 covered persons are eligible for optional family coverage
11 under the Plan.
12 d. For persons qualifying for coverage in accordance
13 with Section 7 of this Act, the board shall, if it determines
14 that such appropriations as are made pursuant to Section 12
15 of this Act are insufficient to allow the board to accept all
16 of the eligible persons which it projects will apply for
17 enrollment under the Plan, limit or close enrollment to
18 ensure that the Plan is not over-subscribed and that it has
19 sufficient resources to meet its obligations to existing
20 enrollees. The board shall not limit or close enrollment for
21 federally eligible individuals.
22 e. A person shall not be eligible for coverage under the
23 Plan if:
24 (1) He or she has or obtains other coverage under a
25 group health plan or health insurance coverage
26 substantially similar to or better than a Plan policy as
27 an insured or covered dependent or would be eligible to
28 have that coverage if he or she elected to obtain it.
29 Persons otherwise eligible for Plan coverage may,
30 however, solely for the purpose of having coverage for a
31 pre-existing condition, maintain other coverage only
32 while satisfying any pre-existing condition waiting
33 period under a Plan policy or a subsequent replacement
34 policy of a Plan policy.
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1 (1.1) His or her prior coverage under a group
2 health plan or health insurance coverage, provided or
3 arranged by an employer of more than 10 employees was
4 discontinued for any reason without the entire group or
5 plan being discontinued and not replaced, provided he or
6 she remains an employee, or dependent thereof, of the
7 same employer.
8 (2) He or she is a recipient of or is approved to
9 receive medical assistance, except that a person may
10 continue to receive medical assistance through the
11 medical assistance no grant program, but only while
12 satisfying the requirements for a preexisting condition
13 under Section 8, subsection f. of this Act. Payment of
14 premiums pursuant to this Act shall be allocable to the
15 person's spenddown for purposes of the medical assistance
16 no grant program, but that person shall not be eligible
17 for any Plan benefits while that person remains eligible
18 for medical assistance. If the person continues to
19 receive or be approved to receive medical assistance
20 through the medical assistance no grant program at or
21 after the time that requirements for a preexisting
22 condition are satisfied, the person shall not be eligible
23 for coverage under the Plan. In that circumstance,
24 coverage under the plan shall terminate as of the
25 expiration of the preexisting condition limitation
26 period. Under all other circumstances, coverage under
27 the Plan shall automatically terminate as of the
28 effective date of any medical assistance.
29 (3) Except as provided in Section 15, the person
30 has previously participated in the Plan and voluntarily
31 terminated Plan coverage, unless 12 months have elapsed
32 since the person's latest voluntary termination of
33 coverage.
34 (4) The person fails to pay the required premium
-4- LRB093 07142 JLS 07297 b
1 under the covered person's terms of enrollment and
2 participation, in which event the liability of the Plan
3 shall be limited to benefits incurred under the Plan for
4 the time period for which premiums had been paid and the
5 covered person remained eligible for Plan coverage.
6 (5) The Plan has paid a total of $2,000,000
7 $1,000,000 in benefits on behalf of the covered person.
8 (6) The person is a resident of a public
9 institution.
10 (7) The person's premium is paid for or reimbursed
11 under any government sponsored program or by any
12 government agency or health care provider, except as an
13 otherwise qualifying full-time employee, or dependent of
14 such employee, of a government agency or health care
15 provider.
16 (8) The person has or later receives other benefits
17 or funds from any settlement, judgement, or award
18 resulting from any accident or injury, regardless of the
19 date of the accident or injury, or any other
20 circumstances creating a legal liability for damages due
21 that person by a third party, whether the settlement,
22 judgment, or award is in the form of a contract,
23 agreement, or trust on behalf of a minor or otherwise and
24 whether the settlement, judgment, or award is payable to
25 the person, his or her dependent, estate, personal
26 representative, or guardian in a lump sum or over time,
27 so long as there continues to be benefits or assets
28 remaining from those sources in an amount in excess of
29 $100,000.
30 (9) Within the 5 years prior to the date a person's
31 Plan application is received by the Board, the person's
32 coverage under any health care benefit program as defined
33 in 18 U.S.C. 24, including any public or private plan or
34 contract under which any medical benefit, item, or
-5- LRB093 07142 JLS 07297 b
1 service is provided, was terminated as a result of any
2 act or practice that constitutes fraud under State or
3 federal law or as a result of an intentional
4 misrepresentation of material fact; or if that person
5 knowingly and willfully obtained or attempted to obtain,
6 or fraudulently aided or attempted to aid any other
7 person in obtaining, any coverage or benefits under the
8 Plan to which that person was not entitled.
9 f. The board or the administrator shall require
10 verification of residency and may require any additional
11 information or documentation, or statements under oath, when
12 necessary to determine residency upon initial application and
13 for the entire term of the policy.
14 g. Coverage shall cease (i) on the date a person is no
15 longer a resident of Illinois, (ii) on the date a person
16 requests coverage to end, (iii) upon the death of the covered
17 person, (iv) on the date State law requires cancellation of
18 the policy, or (v) at the Plan's option, 30 days after the
19 Plan makes any inquiry concerning a person's eligibility or
20 place of residence to which the person does not reply.
21 h. Except under the conditions set forth in subsection g
22 of this Section, the coverage of any person who ceases to
23 meet the eligibility requirements of this Section shall be
24 terminated at the end of the current policy period for which
25 the necessary premiums have been paid.
26 (Source: P.A. 90-30, eff. 7-1-97; 91-639, eff. 8-20-99;
27 91-735, eff. 6-2-00.)
28 (215 ILCS 105/8) (from Ch. 73, par. 1308)
29 Sec. 8. Minimum benefits.
30 a. Availability. The Plan shall offer in an annually
31 renewable policy major medical expense coverage to every
32 eligible person who is not eligible for Medicare. Major
33 medical expense coverage offered by the Plan shall pay an
-6- LRB093 07142 JLS 07297 b
1 eligible person's covered expenses, subject to limit on the
2 deductible and coinsurance payments authorized under
3 paragraph (4) of subsection d of this Section, up to a
4 lifetime benefit limit of $2,000,000$1,000,000 per covered
5 individual. The maximum limit under this subsection shall
6 not be altered by the Board, and no actuarial equivalent
7 benefit may be substituted by the Board. Any person who
8 otherwise would qualify for coverage under the Plan, but is
9 excluded because he or she is eligible for Medicare, shall be
10 eligible for any separate Medicare supplement policy or
11 policies which the Board may offer.
12 b. Outline of benefits. Covered expenses shall be
13 limited to the usual and customary charge, including
14 negotiated fees, in the locality for the following services
15 and articles when prescribed by a physician and determined by
16 the Plan to be medically necessary for the following areas of
17 services, subject to such separate deductibles, co-payments,
18 exclusions, and other limitations on benefits as the Board
19 shall establish and approve, and the other provisions of this
20 Section:
21 (1) Hospital services, except that any services
22 provided by a hospital that is located more than 75 miles
23 outside the State of Illinois shall be covered only for a
24 maximum of 45 days in any calendar year. With respect to
25 covered expenses incurred during any calendar year ending
26 on or after December 31, 1999, inpatient hospitalization
27 of an eligible person for the treatment of mental illness
28 at a hospital located within the State of Illinois shall
29 be subject to the same terms and conditions as for any
30 other illness.
31 (2) Professional services for the diagnosis or
32 treatment of injuries, illnesses or conditions, other
33 than dental and mental and nervous disorders as described
34 in paragraph (17), which are rendered by a physician, or
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1 by other licensed professionals at the physician's
2 direction. This includes reconstruction of the breast on
3 which a mastectomy was performed; surgery and
4 reconstruction of the other breast to produce a
5 symmetrical appearance; and prostheses and treatment of
6 physical complications at all stages of the mastectomy,
7 including lymphedemas.
8 (2.5) Professional services provided by a physician
9 to children under the age of 16 years for physical
10 examinations and age appropriate immunizations ordered by
11 a physician licensed to practice medicine in all its
12 branches.
13 (3) (Blank).
14 (4) Outpatient prescription drugs that by law
15 require a prescription written by a physician licensed to
16 practice medicine in all its branches subject to such
17 separate deductible, copayment, and other limitations or
18 restrictions as the Board shall approve, including the
19 use of a prescription drug card or any other program, or
20 both.
21 (5) Skilled nursing services of a licensed skilled
22 nursing facility for not more than 120 days during a
23 policy year.
24 (6) Services of a home health agency in accord with
25 a home health care plan, up to a maximum of 270 visits
26 per year.
27 (7) Services of a licensed hospice for not more
28 than 180 days during a policy year.
29 (8) Use of radium or other radioactive materials.
30 (9) Oxygen.
31 (10) Anesthetics.
32 (11) Orthoses and prostheses other than dental.
33 (12) Rental or purchase in accordance with Board
34 policies or procedures of durable medical equipment,
-8- LRB093 07142 JLS 07297 b
1 other than eyeglasses or hearing aids, for which there is
2 no personal use in the absence of the condition for which
3 it is prescribed.
4 (13) Diagnostic x-rays and laboratory tests.
5 (14) Oral surgery (i) for excision of partially or
6 completely unerupted impacted teeth when not performed in
7 connection with the routine extraction or repair of
8 teeth; (ii) for excision of tumors or cysts of the jaws,
9 cheeks, lips, tongue, and roof and floor of the mouth;
10 (iii) required for correction of cleft lip and palate and
11 other craniofacial and maxillofacial birth defects; or
12 (iv) for treatment of injuries to natural teeth or a
13 fractured jaw due to an accident.
14 (15) Physical, speech, and functional occupational
15 therapy as medically necessary and provided by
16 appropriate licensed professionals.
17 (16) Emergency and other medically necessary
18 transportation provided by a licensed ambulance service
19 to the nearest health care facility qualified to treat a
20 covered illness, injury, or condition, subject to the
21 provisions of the Emergency Medical Systems (EMS) Act.
22 (17) Outpatient services for diagnosis and
23 treatment of mental and nervous disorders provided that a
24 covered person shall be required to make a copayment not
25 to exceed 50% and that the Plan's payment shall not
26 exceed such amounts as are established by the Board.
27 (18) Human organ or tissue transplants specified by
28 the Board that are performed at a hospital designated by
29 the Board as a participating transplant center for that
30 specific organ or tissue transplant.
31 (19) Naprapathic services, as appropriate, provided
32 by a licensed naprapathic practitioner.
33 c. Exclusions. Covered expenses of the Plan shall not
34 include the following:
-9- LRB093 07142 JLS 07297 b
1 (1) Any charge for treatment for cosmetic purposes
2 other than for reconstructive surgery when the service is
3 incidental to or follows surgery resulting from injury,
4 sickness or other diseases of the involved part or
5 surgery for the repair or treatment of a congenital
6 bodily defect to restore normal bodily functions.
7 (2) Any charge for care that is primarily for rest,
8 custodial, educational, or domiciliary purposes.
9 (3) Any charge for services in a private room to
10 the extent it is in excess of the institution's charge
11 for its most common semiprivate room, unless a private
12 room is prescribed as medically necessary by a physician.
13 (4) That part of any charge for room and board or
14 for services rendered or articles prescribed by a
15 physician, dentist, or other health care personnel that
16 exceeds the reasonable and customary charge in the
17 locality or for any services or supplies not medically
18 necessary for the diagnosed injury or illness.
19 (5) Any charge for services or articles the
20 provision of which is not within the scope of licensure
21 of the institution or individual providing the services
22 or articles.
23 (6) Any expense incurred prior to the effective
24 date of coverage by the Plan for the person on whose
25 behalf the expense is incurred.
26 (7) Dental care, dental surgery, dental treatment,
27 any other dental procedure involving the teeth or
28 periodontium, or any dental appliances, including crowns,
29 bridges, implants, or partial or complete dentures,
30 except as specifically provided in paragraph (14) of
31 subsection b of this Section.
32 (8) Eyeglasses, contact lenses, hearing aids or
33 their fitting.
34 (9) Illness or injury due to acts of war.
-10- LRB093 07142 JLS 07297 b
1 (10) Services of blood donors and any fee for
2 failure to replace the first 3 pints of blood provided to
3 a covered person each policy year.
4 (11) Personal supplies or services provided by a
5 hospital or nursing home, or any other nonmedical or
6 nonprescribed supply or service.
7 (12) Routine maternity charges for a pregnancy,
8 except where added as optional coverage with payment of
9 an additional premium for pregnancy resulting from
10 conception occurring after the effective date of the
11 optional coverage.
12 (13) (Blank).
13 (14) Any expense or charge for services, drugs, or
14 supplies that are: (i) not provided in accord with
15 generally accepted standards of current medical practice;
16 (ii) for procedures, treatments, equipment, transplants,
17 or implants, any of which are investigational,
18 experimental, or for research purposes; (iii)
19 investigative and not proven safe and effective; or (iv)
20 for, or resulting from, a gender transformation
21 operation.
22 (15) Any expense or charge for routine physical
23 examinations or tests except as provided in item (2.5) of
24 subsection b of this Section.
25 (16) Any expense for which a charge is not made in
26 the absence of insurance or for which there is no legal
27 obligation on the part of the patient to pay.
28 (17) Any expense incurred for benefits provided
29 under the laws of the United States and this State,
30 including Medicare, Medicaid, and other medical
31 assistance, maternal and child health services and any
32 other program that is administered or funded by the
33 Department of Human Services, Department of Public Aid,
34 or Department of Public Health, military
-11- LRB093 07142 JLS 07297 b
1 service-connected disability payments, medical services
2 provided for members of the armed forces and their
3 dependents or employees of the armed forces of the United
4 States, and medical services financed on behalf of all
5 citizens by the United States.
6 (18) Any expense or charge for in vitro
7 fertilization, artificial insemination, or any other
8 artificial means used to cause pregnancy.
9 (19) Any expense or charge for oral contraceptives
10 used for birth control or any other temporary birth
11 control measures.
12 (20) Any expense or charge for sterilization or
13 sterilization reversals.
14 (21) Any expense or charge for weight loss
15 programs, exercise equipment, or treatment of obesity,
16 except when certified by a physician as morbid obesity
17 (at least 2 times normal body weight).
18 (22) Any expense or charge for acupuncture
19 treatment unless used as an anesthetic agent for a
20 covered surgery.
21 (23) Any expense or charge for or related to organ
22 or tissue transplants other than those performed at a
23 hospital with a Board approved organ transplant program
24 that has been designated by the Board as a preferred or
25 exclusive provider organization for that specific organ
26 or tissue transplant.
27 (24) Any expense or charge for procedures,
28 treatments, equipment, or services that are provided in
29 special settings for research purposes or in a controlled
30 environment, are being studied for safety, efficiency,
31 and effectiveness, and are awaiting endorsement by the
32 appropriate national medical speciality college for
33 general use within the medical community.
34 d. Deductibles and coinsurance.
-12- LRB093 07142 JLS 07297 b
1 The Plan coverage defined in Section 6 shall provide for
2 a choice of deductibles per individual as authorized by the
3 Board. If 2 individual members of the same family household,
4 who are both covered persons under the Plan, satisfy the same
5 applicable deductibles, no other member of that family who is
6 also a covered person under the Plan shall be required to
7 meet any deductibles for the balance of that calendar year.
8 The deductibles must be applied first to the authorized
9 amount of covered expenses incurred by the covered person. A
10 mandatory coinsurance requirement shall be imposed at the
11 rate authorized by the Board in excess of the mandatory
12 deductible, the coinsurance in the aggregate not to exceed
13 such amounts as are authorized by the Board per annum. At
14 its discretion the Board may, however, offer catastrophic
15 coverages or other policies that provide for larger
16 deductibles with or without coinsurance requirements. The
17 deductibles and coinsurance factors may be adjusted annually
18 according to the Medical Component of the Consumer Price
19 Index.
20 e. Scope of coverage.
21 (1) In approving any of the benefit plans to be
22 offered by the Plan, the Board shall establish such
23 benefit levels, deductibles, coinsurance factors,
24 exclusions, and limitations as it may deem appropriate
25 and that it believes to be generally reflective of and
26 commensurate with health insurance coverage that is
27 provided in the individual market in this State.
28 (2) The benefit plans approved by the Board may
29 also provide for and employ various cost containment
30 measures and other requirements including, but not
31 limited to, preadmission certification, prior approval,
32 second surgical opinions, concurrent utilization review
33 programs, individual case management, preferred provider
34 organizations, health maintenance organizations, and
-13- LRB093 07142 JLS 07297 b
1 other 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
21 following the involuntary termination of that individual
22 health 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
26 payment is available. Subject to the provisions of
27 subsection e of Section 7, benefits otherwise payable
28 under Plan coverage shall be reduced by all amounts paid
29 or payable by Medicare or any other government program or
30 through any health insurance coverage or group health
31 plan, whether by insurance, reimbursement, or otherwise,
32 or through any third party liability, settlement,
33 judgment, or award, regardless of the date of the
34 settlement, judgment, or award, whether the settlement,
-14- LRB093 07142 JLS 07297 b
1 judgment, or award is in the form of a contract,
2 agreement, or trust on behalf of a minor or otherwise and
3 whether the settlement, judgment, or award is payable to
4 the covered person, his or her dependent, estate,
5 personal representative, or guardian in a lump sum or
6 over time, and by all hospital or medical expense
7 benefits paid or payable under any worker's compensation
8 coverage, automobile medical payment, or liability
9 insurance, whether provided on the basis of fault or
10 nonfault, and by any hospital or medical benefits paid or
11 payable under or provided pursuant to any State or
12 federal law or program.
13 (2) The Plan shall have a cause of action against
14 any covered person or any other person or entity for the
15 recovery of any amount paid to the extent the amount was
16 for treatment, services, or supplies not covered in this
17 Section or in excess of benefits as set forth in this
18 Section.
19 (3) Whenever benefits are due from the Plan because
20 of sickness or an injury to a covered person resulting
21 from a third party's wrongful act or negligence and the
22 covered person has recovered or may recover damages from
23 a third party or its insurer, the Plan shall have the
24 right to reduce benefits or to refuse to pay benefits
25 that otherwise may be payable by the amount of damages
26 that the covered person has recovered or may recover
27 regardless of the date of the sickness or injury or the
28 date of any settlement, judgment, or award resulting from
29 that sickness or injury.
30 During the pendency of any action or claim that is
31 brought by or on behalf of a covered person against a
32 third party or its insurer, any benefits that would
33 otherwise be payable except for the provisions of this
34 paragraph (3) shall be paid if payment by or for the
-15- LRB093 07142 JLS 07297 b
1 third party has not yet been made and the covered person
2 or, if incapable, that person's legal representative
3 agrees in writing to pay back promptly the benefits paid
4 as a result of the sickness or injury to the extent of
5 any future payments made by or for the third party for
6 the sickness or injury. This agreement is to apply
7 whether or not liability for the payments is established
8 or admitted by the third party or whether those payments
9 are itemized.
10 Any amounts due the plan to repay benefits may be
11 deducted from other benefits payable by the Plan after
12 payments by or for the third party are made.
13 (4) Benefits due from the Plan may be reduced or
14 refused as an offset against any amount otherwise
15 recoverable under this Section.
16 h. Right of subrogation; recoveries.
17 (1) Whenever the Plan has paid benefits because of
18 sickness or an injury to any covered person resulting
19 from a third party's wrongful act or negligence, or for
20 which an insurer is liable in accordance with the
21 provisions of any policy of insurance, and the covered
22 person has recovered or may recover damages from a third
23 party that is liable for the damages, the Plan shall have
24 the right to recover the benefits it paid from any
25 amounts that the covered person has received or may
26 receive regardless of the date of the sickness or injury
27 or the date of any settlement, judgment, or award
28 resulting from that sickness or injury. The Plan shall
29 be subrogated to any right of recovery the covered person
30 may have under the terms of any private or public health
31 care coverage or liability coverage, including coverage
32 under the Workers' Compensation Act or the Workers'
33 Occupational Diseases Act, without the necessity of
34 assignment of claim or other authorization to secure the
-16- LRB093 07142 JLS 07297 b
1 right of recovery. To enforce its subrogation right, the
2 Plan may (i) intervene or join in an action or proceeding
3 brought by the covered person or his personal
4 representative, including his guardian, conservator,
5 estate, dependents, or survivors, against any third party
6 or the third party's insurer that may be liable or (ii)
7 institute and prosecute legal proceedings against any
8 third party or the third party's insurer that may be
9 liable for the sickness or injury in an appropriate court
10 either in the name of the Plan or in the name of the
11 covered person or his personal representative, including
12 his guardian, conservator, estate, dependents, or
13 survivors.
14 (2) If any action or claim is brought by or on
15 behalf of a covered person against a third party or the
16 third party's insurer, the covered person or his personal
17 representative, including his guardian, conservator,
18 estate, dependents, or survivors, shall notify the Plan
19 by personal service or registered mail of the action or
20 claim and of the name of the court in which the action or
21 claim is brought, filing proof thereof in the action or
22 claim. The Plan may, at any time thereafter, join in the
23 action or claim upon its motion so that all orders of
24 court after hearing and judgment shall be made for its
25 protection. No release or settlement of a claim for
26 damages and no satisfaction of judgment in the action
27 shall be valid without the written consent of the Plan to
28 the extent of its interest in the settlement or judgment
29 and of the covered person or his personal representative.
30 (3) In the event that the covered person or his
31 personal representative fails to institute a proceeding
32 against any appropriate third party before the fifth
33 month before the action would be barred, the Plan may, in
34 its own name or in the name of the covered person or
-17- LRB093 07142 JLS 07297 b
1 personal representative, commence a proceeding against
2 any appropriate third party for the recovery of damages
3 on account of any sickness, injury, or death to the
4 covered person. The covered person shall cooperate in
5 doing what is reasonably necessary to assist the Plan in
6 any recovery and shall not take any action that would
7 prejudice the Plan's right to recovery. The Plan shall
8 pay to the covered person or his personal representative
9 all sums collected from any third party by judgment or
10 otherwise in excess of amounts paid in benefits under the
11 Plan and amounts paid or to be paid as costs, attorneys
12 fees, and reasonable expenses incurred by the Plan in
13 making the collection or enforcing the judgment.
14 (4) In the event that a covered person or his
15 personal representative, including his guardian,
16 conservator, estate, dependents, or survivors, recovers
17 damages from a third party for sickness or injury caused
18 to the covered person, the covered person or the personal
19 representative shall pay to the Plan from the damages
20 recovered the amount of benefits paid or to be paid on
21 behalf of the covered person.
22 (5) When the action or claim is brought by the
23 covered person alone and the covered person incurs a
24 personal liability to pay attorney's fees and costs of
25 litigation, the Plan's claim for reimbursement of the
26 benefits provided to the covered person shall be the full
27 amount of benefits paid to or on behalf of the covered
28 person under this Act less a pro rata share that
29 represents the Plan's reasonable share of attorney's fees
30 paid by the covered person and that portion of the cost
31 of litigation expenses determined by multiplying by the
32 ratio of the full amount of the expenditures to the full
33 amount of the judgement, award, or settlement.
34 (6) In the event of judgment or award in a suit or
-18- LRB093 07142 JLS 07297 b
1 claim against a third party or insurer, the court shall
2 first order paid from any judgement or award the
3 reasonable litigation expenses incurred in preparation
4 and prosecution of the action or claim, together with
5 reasonable attorney's fees. After payment of those
6 expenses and attorney's fees, the court shall apply out
7 of the balance of the judgment or award an amount
8 sufficient to reimburse the Plan the full amount of
9 benefits paid on behalf of the covered person under this
10 Act, provided the court may reduce and apportion the
11 Plan's portion of the judgement proportionate to the
12 recovery of the covered person. The burden of producing
13 evidence sufficient to support the exercise by the court
14 of its discretion to reduce the amount of a proven charge
15 sought to be enforced against the recovery shall rest
16 with the party seeking the reduction. The court may
17 consider the nature and extent of the injury, economic
18 and non-economic loss, settlement offers, comparative
19 negligence as it applies to the case at hand, hospital
20 costs, physician costs, and all other appropriate costs.
21 The Plan shall pay its pro rata share of the attorney
22 fees based on the Plan's recovery as it compares to the
23 total judgment. Any reimbursement rights of the Plan
24 shall take priority over all other liens and charges
25 existing under the laws of this State with the exception
26 of any attorney liens filed under the Attorneys Lien Act.
27 (7) The Plan may compromise or settle and release
28 any claim for benefits provided under this Act or waive
29 any claims for benefits, in whole or in part, for the
30 convenience of the Plan or if the Plan determines that
31 collection would result in undue hardship upon the
32 covered person.
33 (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00;
34 92-2, eff. 5-1-01; 92-630, eff. 7-11-02.)
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