Hospital Sued After Failing to Compensate Insurance Provider for Overpayment

Trustmark Health Benefits, Inc. filed suit against St. Luke’s Health System Corporation last Friday in the Southern District of Texas Houston Division. The suit was brought over allegations that the defendant had received an overpayment from a previous insurance claim and had yet to return it to Trustmark.

Trustmark is the “third-party claims processor for the Primeway Federal Credit Union Employee Health Care Plan,” according to the filing. Trustmark provides claim processing and administration services that help in overseeing the implementation of the plan, adjudicates “the group benefit claims under the terms of the Plan and has authority to pursue recovery of this overpayment on behalf of the Plan.”

A patient who had coverage under the plan received treatment at a non-preferred provider, St. Luke’s, in January 2020. Since the hospital is a non-preferred provider, the complaint said, charges the hospital communicated to the Plan and Trustmark were either not pre-negotiated or not agreed to ahead of time. The total sum of the charges at issue was $34,917.49.

After the charges reached Trustmark, they calculated a net payment due of $30,919.63. Upon fulfillment of the payment, overpayment was discovered during a routine audit. The total overpayment amount was determined to be $24,346.73. Trustmark explains in their complaint that they notified St. Luke’s of the overpayment and amount due back in repeated letters, stating. “St. Luke’s refuses to respond to any of Trustmark’s correspondence and has not refunded any part of the overpayment to the Plan.”

The complaint cites restitution pursuant to 29 U.S.C. to recover overpayment, unjust enrichment, and money had and received. Trustmark is seeking favorable judgement regarding the defendant’s responsibility to pay, actual, economic, and consequential damages, reasonable attorney’s fees, pre and post-judgement interest, and any other relief deemed proper.

The plaintiff is represented by Figari Davenport.