The insurance refund request: a legal analysis

Healthc Financ Manage. 1998 Dec;52(12):52-4.

Abstract

When an insurance payment is made erroneously to a healthcare provider and no contract between the insurer and provider addresses the issue of refunding such payments, the law relating to restitution generally applies. Restitution does not apply, however, to three exceptions that the courts have used to refuse claims by insurers for refunds of overpayments: the innocent third-party creditor exception, whereby the healthcare provider cannot be unjustly enriched by the overpayment, cannot have induced the mistaken payment, and cannot have known beforehand that the insurer was not obligated to pay; the material change in position exception, whereby the healthcare provider in good faith accepts an overpayment and so does not pursue other means of payment; and the assumption of the risk exception, which occurs when the insurer pays a claim without having complete information about it.

MeSH terms

  • Financial Management / legislation & jurisprudence*
  • Insurance Carriers
  • Insurance Claim Reporting / legislation & jurisprudence
  • Insurance, Health, Reimbursement / legislation & jurisprudence*
  • Time Factors
  • United States