Injured Person's Responsibilities

The JAG designee advises the injured person of his or her legal obligations under the MCRA. These responsibilities arc as follow: . Furnish the JAG designee with any pertinent information about the incident . Notify the JAG designee of any settlement offer from the liable part y or that party's insurers . Cooperate in the prosecution of the government's claim against the liable party . Give the JAG designee the name and address of any civilian attorney representing the injured party, since the civilian attorney may represent the government as well as the injured person if the claim is litigated in court . Refuse to execute a release or settle any claim concerning the injury without the prior approval of the JAG designee . Refuse to provide any information to the liable party, that party's insurer, or attorney without prior approval of the JAG designee At first, these restrictions and obligations may appear unfair. But, it must be remembered that the government's rights under the MCRA are largely derivative from the injured person's legal rights. If the injured person makes an independent settlement with the liable party, the government's rights could be prejudiced. Also, if the injured person settles the claim independently and receives compensation for medical expenses, the government is entitled to recover its MCRA claim from the injured person directly out of the proceeds of the settlement.

JAG Designee Action

The JAG designee formally asserts the government's MCRA claim by mailing a Notice of

Claim to the liable party or insurer the includes the

following information:

Reference to the statutory right to collect

A demand for payment or restoration

A description of damage

The date and place of the accident

The name, phone number, and office address of the claims personnel to contact

The JAG designee may accept full payment of the claim or may establish an installment payment plan with the liable party. Under appropriate circumstances, the JAG designee may waive or compromise the claim. Waivers or compromises of claims in excess of $40,000 require prior Department of Justice approval. If the

Figure 12-5B.-Sample NAVJAG Form 5890/12, Report of Hospital and Medical Care-Third Party Liability, Supplemental Statement (back).

claim cannot be collected locally, referral to the Department of Justice for litigation is possible, but this must be done by JAG.

MEDICAL PAYMENTS INSURANCE COVERAGE

Government claims for medical care normally are directed against the tortfeasor and recovery is obtained either directly from him or her or the insurance carrier. There are, however, other potential sources for recovery of medical care expenditures, depending upon the circumstances involved.

One such potential source is medical payments ^{insurance coverage.} Under the provisions of certain automobile insurance policies, an insurer may be obligated to pay the cost of medical care for injuries incurred by the policyholder, his or her passengers who are riding in the insured vehicle, or a pedestrian who is struck by the insured vehicle. Assuming such coverage exists (and it is the claims officer's responsibility to determine if it does), medical payments clauses apply regardless of who was at fault and the United States may be entitled to recover as the provider of medical care. It is extremely important to note that recovery has been allowed, based on one of two theories: (1) that the United States is insured under the medical pay provisions of the insurance policy or (2) that the United States is a third-party beneficiary of the insurance contract. Recovery is not based upon the MCRA, but under the terms of the individual insurance policy.

UNINSURED MOTORIST COVERAGE

Another potential source of recovery of medical care costs is the uninsured motorist coverage provisions of the typical automobile insurance policy. If an injured service member has obtained such coverage, and the tortfeasor is uninsured, the typical uninsured motorist coverage clause provides for payment to the policyholder of those sums that he or she would have been able to recover from the tortfeasor, but for the fact that the tortfeasor was uninsured. Like medical payments insurance coverage, the right of the United States to recover is based upon the terms of the insurance contract and not upon the MCRA. If the term insured includes any person, then the courts have generally held that the United States is entitled to recover.

NO-FAULT STATUTES

The recovery of the United States under the MCRA in states that have enacted no-fault statutes will be determined by the language of the statute. It is necessary to determine if the United States is within the terms of the statute so as to be entitled to recover for medical care provided. If the state statute eliminates a cause of action against the tortfeasor, then the only probable source of recovery is under the injured party's no-fault insurance. If the United States is excluded and has no cause of action, then there maybe no recovery in the particular case.

AFFIRMATIVE CLAIMS AGAINST SERVICE MEMBER TORTFEASER

The United States may not assert an affirmative claim against a service member or employee who, while in the scope of employment, damages government property or causes damage or injury for which the United States must pay. Consideration, in the case of gross negligence or willful and wanton acts, should be given to whether such actions took the service member or employee outside the scope of employment.

CLAIMS MANAGEMENT

As a senior LN, your knowledge in claims accounting procedures must be thorough. You need to be familiar with the many budget projects out of which claims are paid. The following will present an overview of how to manage a claims accounting system.

MANAGING NAVY CLAIMS FUNDS

Managing claims funds should be no more difficult than taking care of a checking account. Checks (vouchers) and deposits (case collection vouchers and fund authorizations) arc recorded in a checkbook (memorandum accounting logbook). They are processed by a bank (accounting activity) which then sends out bank statements (accounting reports). These are used to reconcile what actually has been recorded by the bank (accounting activity) against what should have been recorded as indicated in your checkbook (memorandum accounting logbook). While the bank statement is usually correct and reconciliation can be delayed, the accounting reports must be reconciled each month due to the possibility of input error or missing documents. Therefore, you must reconcile monthly with authorization accounting activities.