Plaintiff and members of the Class are insureds under CareFirst healthcare plans, some of whose claims arise under ERISA. The Plaintiff was injured in an accident and was treated for covered services by a State licensed network of preferred medical providers under contract with and administered by the Defendants on behalf of its various health insurance plans, including the group policy sold to her employer, Loyola College.
As a member of a Plan, Plaintiff was entitled to treatment from Defendants' network of preferred healthcare providers; and except for co-pays, deductibles and other permissible coinsurance. Defendants are charged under law and contract, to hold its members harmless for any additional fees charged by any provider for covered services other than the premiums paid.
Plaintiff also purchased no fault coverage or PIP as part of her automobile insurance with GEICO in an amount not less than $2,500. Under this PIP Statute, the Plaintiff is entitled to receive PIP payments as additional first-party insurance (or collateral source) covering among other expenses medical bills arising out of automobile accidents. PIP is not co-insurance that can be coordinated with other managed healthcare plans except as provided for under the specific terms of the PIP Statute - chief among them the filing of a discounted premium by the healthcare insurer approved by the Maryland Insurance Administration, and agreed to by its insureds in writing, consenting to the coordination of those PIP benefits by the healthcare insurer.
None of Defendants' licensed healthcare insurance plans has ever offered in its rate filings a premium discount in exchange for permitting any healthcare insurance plan to appropriate an insured's PIP benefits or otherwise sought the written consent prior to an insured's involvement in an auto accident to coordinate the insured's PIP benefits.
Contrary to Maryland law and their own contracts with its network of preferred healthcare providers, the Defendants uniformly instruct those providers to bill each members' PIP coverage (to exhaustion) before the Defendants will pay for covered services under its healthcare policy. As a result, when Plaintiff sought medical treatment following her auto accident the three healthcare professionals within the Defendants' network and from whom she obtained treatment, rather than billing the Defendants, directly billed the Plaintiffs auto insurer collecting PIP payments in the amount of $631.59 that without the aforesaid consent actually belonged to the Plaintiff.
