Georgia's Made-Whole Statute: When Your Health Insurer Can Be Repaid

By the FigureMyTax Editorial Team · How we calculate

Under Georgia's statute, a health insurer or other benefit provider may require reimbursement only if your recovery exceeds all your economic and noneconomic losses, and then its claim is reduced by its pro rata share of your attorney fees and litigation expenses.

The rule

O.C.G.A. 33-24-56.1(b) says a benefit provider may require reimbursement from the injured party, up to the amount allocated to those categories of damages in the settlement documents or judgment, only if (1) the recovery exceeds the sum of all economic and noneconomic losses from the injury, not counting losses for which reimbursement may be sought, and (2) the claim is reduced by the pro rata amount of the attorney fees and expenses of litigation the injured party incurred in bringing the claim.

When you are not made whole

If a settlement is claimed not to exceed your losses, the benefit provider may seek a declaratory judgment on how far it can equitably share. If the court finds the settlement does not fully and completely compensate you, the benefit provider has no right of reimbursement (subsection (c)). At trial, the trier of fact may allocate the amounts paid among the damages categories, and that allocation is conclusively presumed reasonable (subsection (d)).

A worked example

Suppose your total losses are $300,000 and you settle for $100,000. You are not fully compensated, so a health plan that paid $9,000 gets $0. If instead your losses were $90,000 and you settled for $100,000, the plan could claim up to $9,000, reduced by your fee-and-cost share of about 36.3%, so about $5,730. The Georgia medical lien calculator asks whether you are fully compensated.

Other protections

Subrogation by a benefit provider against the at-fault person is prohibited, and a defendant or liability insurer cannot name a reimbursing insurer as a co-payee on the settlement check (subsection (e)). The benefit provider cannot reduce what it owes you under liability, UM, disability or medical payments coverage as a setoff, or withhold benefits to enforce reimbursement (subsection (f)). You must send notice of your claim to each benefit provider no later than ten days before settlement or trial, and a provider's claim is enforceable only to the extent you have actual itemized notice of it before settlement or trial ((g) to (i)).

Limits of the statute

It does not apply to the Department of Community Health's Medicaid recovery or to workers' compensation subrogation (subsection (l)), and a self-funded federal plan may not be bound by a state statute, so ask for the plan document. Policy terms in conflict with the statute cannot be enforced (subsection (j)). See the Medicaid post and how provider liens differ.

This is general information, not legal advice, and the state comparisons above are illustrative, not an exhaustive survey. Confirm how Georgia's rules apply to your specific case with a licensed Georgia attorney.