## Facts

- Margaret Shallenberger became a Harris employee in 1991 and enrolled in Harris’s employee health plan while remaining covered as a dependent under a Humana group plan sponsored by the City of Fort Lauderdale.
- In 1992, Shallenberger qualified for and elected long-term disability benefits through Harris.
- In 1994, she became entitled to Medicare Parts A and B due to disability; she died in 1995.
- From Shallenberger’s Medicare eligibility through her death, the Harris plan paid about $780,267.88 in medical benefits and recovered about $13,643.99 from providers.
- Medicare refused to reimburse Harris, citing Shallenberger’s other available coverage; Humana also refused to reimburse Harris.
- The Humana plan contained an express coordination-of-benefits (COB) provision stating that a plan without a COB provision is deemed to determine benefits before a plan with a COB provision.
- The Harris plan lacked an internal COB provision and instead contained a nonduplication clause that did not address the specific spouse-dependent, dual-coverage scenario.
- The district court granted summary judgment for Humana, concluding Harris was primary under the plans and could not obtain reimbursement; Harris appealed, and Humana cross-appealed.

## Issues

1. Whether, under the Medicare Secondary Payer Act (MSPA) and the competing plan terms, Humana or Harris was the primary payer for Shallenberger’s medical expenses.
2. Whether Humana’s COB clause made Harris primary when Harris’s plan lacked a COB provision but included a nonduplication clause.
3. Whether the MSPA created or supported a reimbursement right by Harris against Humana that overrides the plans’ allocation of payment responsibility.

## Decision

- The Eleventh Circuit affirmed summary judgment for Humana.
- The court held the Harris plan was primary based on the plans’ terms and Harris had no contractual right to reimbursement from Humana.
- The court held the MSPA did not alter the payment order between the two private plans to make Humana primarily liable to Harris.

## Legal Principles

- Priority between overlapping group health plans is determined by the plans’ written terms, including coordination-of-benefits provisions.
- Where one plan’s COB provision states that a non-COB plan pays first, the non-COB plan is treated as primary as between the two plans, absent contrary language in the non-COB plan.
- A nonduplication clause that does not address the specific dual-coverage scenario may not displace another plan’s explicit COB priority rule.
- The MSPA governs Medicare’s status as a secondary payer and Medicare’s recovery rights; it does not, without a supporting contractual or statutory basis, reallocate payment duties between two private health plans or create a reimbursement claim by one private plan against another.

## Conclusion

The court enforced the plans’ coordination terms and concluded Harris was the primary payer; the MSPA did not convert Humana into a primary payer vis-à-vis Harris or supply Harris with a reimbursement right against Humana.


Harris Corp. v. Humana Health Ins. Co. of Fla., Inc., 253 F.3d 598 (11th Cir. 2001)