Here are the "guts" of the letter that I typically use when a HI collection agency jumps into a claim:
This acknowledges receipt of your letter informing of a potential subrogation or right of reimbursement regarding the contract of health insurance between our client and yours. I request that you provide us with a copy of the summary plan as well as the language that allows you, as the agent for the fiduciary health insurer in this instance, to make a subrogation or right of reimbursement claim. Please inform me in writing if it is your intention to assent subrogation or a right of reimbursement.
At this time, we acknowledge your correspondence and potential claim. Please note, however, that I cannot make a determination as to the validity of the fiduciary’s right to recover–if any– unless or until a copy of the plan is provided.
First: I ask for written documentation from the Health Plan that confirms your company’s right to make a claim on behalf of the plan.
Second: Please do not make the mistake of responding to this letter by stating that your entity is not the plan administrator and my request for a copy of the relevant documents is to be made to the plan. You are clearly acting as an agent for the health insurer. You are making a request/demand for information and reimbursement and I am asking for documentation to support such a claim as it relates to the contract for health benefits.
Third: I consider your company a fiduciary of the plan. If you disagree, please let me
know why, doing so in writing within ten days.
My obligation in my contract rests solely with my client, a person injured through no fault of her own. As of the date of this letter, there is no recovery of any nature. When or if there is a recovery, I will consult my client. I will not provide you with updates of his treatment or his care. Do not contact my client. If the client agrees, I will be happy to contact you once my client’s care has ended and if or when an offer is made by the at fault party.
I may assert the common fund doctrine at some point. Please inform me if you intend to take the position that the common fund doctrine does not apply. Of course, I request that if your company takes such a position that you support it in writing. It is our firm’s legal conclusion that if the common fund doctrine applies, it does so regardless of the settlement offer(s) ultimately made.
Unless or until you are informed in writing that our legal representation has come to an end at any point, always know that we are the insured’s attorneys.
Feel free to call me if you wish further explanation. I do need the documentation requested so that I may fully explain to my client the nature and validity of the claim asserted.
It goes by certified mail. We have several cases pending where the 30 day rule has not been met. At least once we have sued and won on the issue of the common fund doctrine in Georgia.
