Maine Revised Statutes Title 24-A Sec. 4243 – Limits on priority liens; subrogation
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An individual or group contract subject to this chapter may not provide for subrogation or priority over the enrollee of payment for any hospital, nursing, medical or surgical services or of any expenses paid or reimbursed under the coverage, in the event the enrollee is entitled to receive payment or reimbursement from any other person as a result of legal action or claim, except as provided in this section. [PL 1997, c. 369, §3 (NEW).]
The coverage may contain a provision that allows the payments, if that provision is approved by the superintendent and if that provision required the prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. A “just and equitable basis” means that any factors that diminish the potential value of the enrollee’s claim may likewise reduce the share in the claim for those claiming payment for services or reimbursement. Such factors include, but are not limited to: [PL 1997, c. 369, §3 (NEW).]
1. Legal defenses. Questions of liability and comparative negligence or other legal defenses;
[PL 1997, c. 369, §3 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4243
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means an individual who is enrolled in a health maintenance organization. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. Source: U.S. Courts
- Lien: A claim against real or personal property in satisfaction of a debt.
- Person: means an individual, firm, partnership, corporation, association, syndicate, organization, society, business trust, attorney-in-fact or any legal entity. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
- Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
2. Exigencies of trial. Exigencies of trial that reduce a settlement or award in order to resolve the claim; and
[PL 1997, c. 369, §3 (NEW).]
3. Limits of coverage. Limits on the amount of applicable insurance coverage that reduce the claim to an amount recoverable by the insured.
[PL 1997, c. 369, §3 (NEW).]
In the event of a dispute as to the application of any such provision or the amount available for payment to those claiming payment for services or reimbursement, that dispute must be determined, if the action is pending, before the court in which it is pending; or if no action is pending, by filing an action in any court for determination of the dispute. [PL 1997, c. 369, §3 (NEW).]
Revisor’s Note: §4243. Coverage for prostate cancer screening (As enacted by PL 1997, c. 754, §4 is REALLOCATED TO TITLE 24-A, SECTION 4244)
SECTION HISTORY
RR 1997, c. 2, §53 (RAL). PL 1997, c. 369, §3 (NEW). PL 1997, c. 754, §4 (NEW).