Skip to Navigation
The Collaborative Clearinghouse for Lawsuits and Other Claims Against ACE Group Insurance Companies

CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND v. HEALTH SPECIAL RISK INC et al

ATTENTION: It is possible that this information may no longer be current and therefore may be inaccurate. The index contains both open and closed cases and is not a complete list of cases in which an ACE Insurance Group company is involved. This information is provided to give interested persons an idea of the issues disputed in the indexed cases. For a full understanding of a case, one should read the rest of the court file, including the response. For the most up-to-date and complete information on a case, visit www.pacer.gov or contact the clerk of the relevant court.

Case Number: 
3:11-cv-02910 Search Pacer
ACE Group party(s): 
Opposing Party: 
Central States, Southeast and Southwest Areas Health and Welfare Fund
Court Type: 
Federal
US District Court: 
Northern District of Texas
Date Filed: 
Oct 28 2011

"Count I Declaratory Judgment

39. Central States restates and realleges the allegations made in paragraphs 1 through 38 of this complaint, as it fully restated and realleged herein.

40. Central States thereby requests that this Court examine Central States Plan and each of the Defendants' medical accident insurance policies and declare the liability of the Defendants to pay, past, present and future covered medical expenses, relating to the accidental injuries sustained by the eleven Covered Individuals in activities, which were covered by both Central States Plan and the Defendants' medical accident insurance policies.

41. Central States requests this Court to examine the COB provisions contained in Central States Plan, and the COB and/or Other Insurance provisions of the Defendants' medical accident insurance policies, and find that an actual controversy exists between
Central States and each of the Defendants as to their rights and other legal obligations, with respect to the primary responsibility for payment of the covered medical expenses of the eleven Covered Individuals, which controversy can only be determined in each case by a declaratory judgment issued by the Court.

42. Central States requests that this Court declare that the COB provisions of Central States Plan may and should be enforced against the Defendants, by requiring the Defendants pay covered medical expenses of the eleven Covered Individuals as primary and to fully reimburse Central States for payments already made by Central States on behalf of the eleven Covered Individuals for their covered medical expenses.

WHEREFORE, Central States requests that this Court:
a. Declare as between Central States and each of the Defendants, that the Defendants had, and continue to have, as Other Plans as defined in the COB rules stated in Central States Plan, primary responsibility for paying all the covered medical expenses, which have been paid by Central States on behalf of the eleven Covered Individuals, relating to accidental injuries incurred by the Covered Individuals, and to pay their future medical expenses, and that Central States liability is to only pay as secondary;
b. Enter an order of injunctive relief against HSR, in its capacity as TPA for Markel, Federal and Ace American, enjoining HSR from violating the COB provisions of Central States Plan when it acts as a TPA for Markel, Federal and Ace American, in cases in which it administers claims involving Central States Covered Individuals, so as to afford full equitable relief to Central States;
c. Enter orders of injunctive relief against Defendants Markel, Federal and Ace American enjoining each of them from violating the COB provisions of Central States Plan;
d. Grant such other relief as the Court deems just and proper;
e. Award costs and reasonable attorney's fees in favor of Central States against the Defendants.

Count II Restitution of Payments Made

43. Central States restates and realleges the allegations made in paragraphs 1 through 42 of this complaint, as if fully restated and realleged herein.

44. Central States has paid and continues to pay, the covered medical expenses for the eleven Covered Individuals, relating to the accidental injuries they sustained. The unreimbursed amount paid by Central States, on behalf of the Covered Individuals, in cases of policies administered by HSR for Markell is $66,414.59 (Exhibit M), in the case of a policy administered by HSR for Federal is $2,973.95 (Exhibit N), and in cases of policies administered by HSR for Ace American is $12,662.11 (Exhibit O).

45. Central States Plan provides that whenever the Plan has made benefit payments which exceed the amount of benefits payable under its terms, or which an Other Plan was required to make, Central States shall have the right to recover the excess payments from any responsible persons or entities, including any Other Plans having primary responsibility for the payment of said benefits.

46. The COB provisions of Central States Plan require the Defendants, as Other Plans, to make payments under each of their medical accident insurance polies for the covered medical expenses incurred by the eleven Covered Individuals for accidental injuries sustained by them, but the Defendants have failed and refused to make any payments.

47. Because Central States has paid the covered medical expenses of the eleven Covered Individuals, and the Defendants have failed and refused to pay their medical expenses, except as excess after Central States has paid, even though the Defendants are liable under the terms of Central States Plan's COB provisions to pay as primary, then in order to enforce the terms of an ERISA regulated welfare benefit plan, the Defendants are subject to an order of equitable relief requiring them to make restitution to Central States of an identifiable amount consisting of the unreimbursed covered medical expenses Central States has overpaid on behalf of the eleven Covered Individuals.

WHEREFORE, Central States requests that this Court:
a. Enter an order of equitable relief, in the form of restitution of an identifiable amount, to enforce Central States Plan and reimburse Central States the sum of $66,414.59, plus interest against HSR and Markel for overpayments made by it on behalf of six Covered Individuals for their medical expenses incurred for accidental injuries, who were also insured for said injuries under accident insurance policies issued by Markel and administered by HSR, and for whom, pursuant to the COB provisions of Central States Plan, it is the responsibility of HSR and Markel to pay;
b. Enter an order of equitable relief, in the form of restitution of an identifiable amount, to enforce Central States Plan and reimburse Central States the sum of $2,973.95, plus interest against HSR and Federal for overpayments made by it on behalf of one Covered Individual for his medical expenses incurred for accidental injuries, who was also insured for said injuries under accident insurance policies issued by Federal and administered by HSR, and for whom, pursuant to the COB provisions of Central States Plan, it is the responsibility of HSR and Federal to pay;
c. Enter an order of equitable relief, in the form of restitution, of an identifiable amount to enforce Central States Plan and reimburse Central States the sum of $12,662.11, plus interest against HSR and Ace American for overpayments made by it on behalf of four Covered Individuals for their medical expenses incurred for accidental injuries, who were also insured for said injuries under accident insurance policies issued by Ace American and administered by HSR, and for whom, pursuant to the COB provisions of Central States Plan, it is the responsibility of HSR and Ace American to pay;
d. Grant such other relief as the Court deems just and proper;
e. Award costs and reasonable attorney's fees in favor of Central States against the Defendants.

Count III Equitable Lien/Constructive Trust

48. Central States restates and realleges the allegations made in paragraphs 1 through 47 of this complaint, as if fully restated and realleged herein.

49. Because the Defendants, as Other Plans, as defined in the COB rules stated in Central States Plan, should have paid the covered medical expenses which were paid by Central States for the eleven Covered Individuals, by wrongfully withholding reimbursement of said amounts to Central States, the Defendants are unjustly enriched to the extent of Central States' overpayments, and each of the Defendants are thus in possession of assets, as stated herein, in an identifiable amount, of an employee welfare benefit plan, which in equity and good conscience belong to Central States.

50. Because the Defendants have failed and refused to pay, except as excess to Central States, the covered medical expenses for the eleven Covered Individuals, and Central States has paid, and will continue to pay said expenses, Central States has thus made benefit payments which exceed the amount of benefits payable under the terms of Central States Plan, and thereby has a right to recover excess payments from any responsible persons or entities, including any Other Plans which have primary responsibility for the payment of said benefits.

51. The Defendants are responsible entities and Other Plans obligated to repay excess payments to Central States.

52. Central States thus seeks equitable relief against each of the Defendants, by the imposition of an equitable lien upon amounts constructively held by the Defendants for the benefit of Central States, in the current identifiable amount of $66,414.59 (Exhibit
M) against HSR and Markel, and in the current identifiable amount of $2,973.95 (Exhibit
N) against HSR and Federal, and in the current identifiable amount of $12,662.11 (Exhibit
O) against HSR and Ace American.

53. Equitable liens in favor of Central States may be enforced by a constructive trusts upon wrongfully withheld assets in the constructive possession of the Defendants, with the constructive trusts to continue until full restitution is made by each Defendant to Central States."

The provided text is an excerpt from a document filed in this case. For a full understanding of the case, one should read the complete court file, including the response.

Javascript is required to view this map.