ERISA Health Plan Lien Calculation Worksheet

ERISA HEALTH PLAN LIEN CALCULATION WORKSHEET

Case Name: [________________________________]
Case/Claim Number: [________________________________]
Date of Injury: [__/__/____]
Date Prepared: [__/__/____]
Prepared By: [________________________________]

SECTION 1: PLAN IDENTIFICATION

Plan Information:

Subrogation Contact:

SECTION 2: ERISA STATUS DETERMINATION

Critical Question: Is the Plan Self-Funded?

☐ Self-Funded (Self-Insured) Plan

• Employer pays claims directly from general assets
• May have stop-loss insurance for catastrophic claims
• Subject to ERISA preemption of state insurance laws
• Federal law governs subrogation rights

☐ Fully Insured Plan

• Insurance company assumes risk and pays claims
• Subject to state insurance regulations
• May have more flexibility for lien reduction

How to Determine Funding Status:

☐ Review Summary Plan Description (SPD)
☐ Request Form 5500 (filed with DOL)
☐ Ask employer HR department
☐ Review plan document for funding language
☐ Contact claims administrator

Funding Status Evidence:
[________________________________]
[________________________________]

Stop-Loss Insurance (Does Not Change Self-Funded Status):

☐ Plan has stop-loss/reinsurance coverage
☐ Specific deductible: $ [________________]
☐ Aggregate deductible: $ [________________]

Important: Stop-loss coverage does not convert a self-funded plan to an insured plan. The plan remains self-funded and subject to ERISA preemption.

SECTION 3: PLAN DOCUMENT ANALYSIS

Key Plan Language Review:

A. Subrogation/Reimbursement Clause:

☐ Plan contains subrogation clause
☐ Plan contains reimbursement clause
☐ Both subrogation and reimbursement

Quote Key Language:
[________________________________]
[________________________________]
[________________________________]

B. Made Whole Doctrine Language:

☐ Silent - Made whole doctrine may apply as default
☐ Expressly Adopts - Made whole doctrine applies
☐ Expressly Rejects - Plan recovers first dollar regardless of whether participant is made whole
☐ Modifies - Describe: [________________________________]

Quote Key Language:
[________________________________]
[________________________________]

C. Attorney Fee/Common Fund Language:

☐ Silent - Common fund doctrine may apply per McCutchen
☐ Expressly Requires Fee Sharing - Plan reduces by proportionate attorney fees
☐ Expressly Prohibits Fee Sharing - Plan does not reduce for attorney fees
☐ Other - Describe: [________________________________]

Quote Key Language:
[________________________________]
[________________________________]

D. Recovery Priority Language:

☐ Plan has first-priority recovery right
☐ Plan recovers after participant reimbursed
☐ Pro rata recovery
☐ Other: [________________________________]

SECTION 4: LIEN AMOUNT CALCULATION

A. Claimed Lien Amount:

B. Lien Verification:

C. Disputed/Non-Related Charges:

D. Verified Lien Amount:

SECTION 5: REDUCTION ANALYSIS

A. Made Whole Analysis (If Applicable):

Is Made Whole Doctrine Available?

Per US Airways v. McCutchen, the made whole doctrine is a default equitable rule that can be displaced by express plan language.

If Made Whole Applies:

Is Client Made Whole?
☐ Yes (Net recovery ≥ Total damages) - Lien fully enforceable
☐ No (Net recovery < Total damages) - Made whole reduction applies

Made Whole Reduction:

B. Common Fund/Attorney Fee Reduction (McCutchen):

Per US Airways v. McCutchen, if plan is silent on attorney fees, unjust enrichment principles require the plan to share in litigation costs.

If Common Fund Applies:

C. Comparative Fault Reduction:

D. Combined Reduction Calculation:

SECTION 6: STATE LAW CONSIDERATIONS

Applicable State: [____]

State Law Lien Reduction Statutes:

ERISA Preemption Analysis:

☐ Plan is self-funded - State law is preempted
☐ Plan is insured - State insurance law may apply
☐ Analysis uncertain - Further review needed

Applicable State Law:
[________________________________]
[________________________________]

SECTION 7: NEGOTIATION STRATEGY

Available Arguments:

☐ Made whole - Client not fully compensated
☐ Common fund - Plan must share attorney fees (if silent)
☐ Comparative fault - Recovery reduced by client's fault
☐ Disputed charges - Payments not related to accident
☐ Insufficient recovery - Policy limits, judgment proof defendant
☐ Financial hardship - Client's circumstances
☐ Future medical needs - Ongoing care required
☐ Relationship value - Ongoing employer relationship

Proposed Reduction Request:

Justification for Reduction:

[________________________________]
[________________________________]
[________________________________]
[________________________________]

SECTION 8: NEGOTIATION LOG

SECTION 9: RESOLUTION

Final Agreement:

Resolution Documentation:

☐ Written settlement agreement obtained
☐ Lien reduction letter received
☐ Payment instructions confirmed
☐ Release/satisfaction prepared

Payment Information:

SECTION 10: DOCUMENTATION CHECKLIST

Plan Documents:

☐ Summary Plan Description (SPD)
☐ Full Plan Document
☐ Subrogation/Reimbursement provisions
☐ Amendment history
☐ Form 5500 (for funding status)

Lien Documentation:

☐ Initial lien letter
☐ Itemized payment records
☐ EOBs for all payments
☐ Updated lien statements
☐ Correspondence with subrogation vendor

Settlement Documentation:

☐ Settlement agreement/release
☐ Settlement breakdown letter to lienholder
☐ Proof of attorney fees and costs
☐ Comparative fault evidence
☐ Made whole calculation
☐ Negotiation correspondence
☐ Final lien reduction agreement
☐ Payment receipt
☐ Lien release/satisfaction

SECTION 11: KEY CASE LAW REFERENCE

US Airways, Inc. v. McCutchen, 569 U.S. 88 (2013)

• Plan terms govern subrogation rights for self-funded ERISA plans
• If plan is silent, equitable doctrines (common fund) may apply
• Express plan language can override equitable defenses

Sereboff v. Mid Atlantic Medical Services, Inc., 547 U.S. 356 (2006)

• ERISA plans can enforce reimbursement rights via equitable lien
• Action under § 502(a)(3) is equitable in nature

Great-West Life & Annuity Ins. Co. v. Knudson, 534 U.S. 204 (2002)

• ERISA § 502(a)(3) limits recovery to equitable relief
• Must trace funds to identifiable res

CERTIFICATION

I certify that this ERISA lien analysis is based on available plan documents, payment records, and applicable law. This worksheet is for settlement calculation purposes and final lien resolution should be confirmed in writing with the plan.

Signature: ________________________________________ Date: [__/__/____]

Print Name: [________________________________]

Title: [________________________________]

SOURCES AND REFERENCES

• US Airways, Inc. v. McCutchen, 569 U.S. 88 (2013)
• Sereboff v. Mid Atlantic Medical Services, Inc., 547 U.S. 356 (2006)
• FindLaw: Tips for Negotiating ERISA Liens in Personal Injury Cases
• Synergy Settlement Services: ERISA Plan Subrogation and Reimbursement
• Advocate Magazine: ERISA Liens and Self-Funded Plans

This worksheet is for informational purposes only. ERISA subrogation is a complex area of federal law. Consult legal counsel experienced in ERISA matters for case-specific advice.