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- Title
HEALTH INSURANCE--PROVIDER DISCOUNTS.
- Abstract
The article presents information on the case, McConocha v. Blue Cross and Blue Shield of Ohio. Where a group health insurer paid less than the 80% of eligible medical expenses its contract required it to pay because it had separately negotiated a discounted fee schedule with the medical provider, the employer's president and employee were entitled to recover the difference between the copayment of 20% of the total amount of medical expenses billed, and 20% of the discounted amount actually paid to the hospital by the insurer. Any discounted fee schedule must be disclosed. The discount cannot benefit the insurer at the expense of the insured. McConocha sued Blue Cross and Blue Shield under Employee Retirement Income Security Act for benefits and breach-of-fiduciary duty. First, the court determined that McConocha could sue as an employee even though he was the corporation's majority shareholder because he is also insured under the health plan. Second, the court found Blue Cross/Blue Shield liable to McConocha for the difference between the amount of his copayment to the hospitals and 20% of the total amount received by the hospitals.
- Subjects
ACTION &; defense cases; HEALTH insurance; ACTIONS &; defenses (Law); MEDICAL care; RETIREMENT income; PUBLIC health
- Publication
Benefits Quarterly, 1997, Vol 13, Issue 3, p103
- ISSN
8756-1263
- Publication type
Article