Mobley ex rel. Mobley v. State
181 So. 3d 1233
Fla. Dist. Ct. App.2015Background
- In 2005 Michael Mobley (then 14) suffered anoxic brain injury after drowning at a hotel party; he required long‑term care.
- Parents sued third parties; total claimed past medical expenses were $627,804.14 (ERISA plan $515,860.29; Medicaid $111,943.89).
- Parties settled all claims for $500,000; ERISA agreed to accept $120,000 in satisfaction of its lien; AHCA asserted full Medicaid lien ($111,943.89).
- Appellant filed a § 409.910 petition to determine the correct Medicaid lien amount, arguing the settling parties allocated only ~3.3% of damages to medical expenses, yielding a $20,717.54 allocation to Medicaid.
- The ALJ treated the settlement sheet as allocating $120,000 to ERISA and $20,717.53 to Medicaid, combined them as $140,717.53 allocated to medical expenses, and ordered AHCA reimbursed in full.
- The court found the ALJ erred by treating the ERISA payment as evidence of allocation to medical expenses because ERISA liens may be satisfied from any portion of a settlement.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether settlement allocated $140,717.53 to medical expenses | Mobley: parties’ proportional allocation of the $500,000 settlement means Medicaid received only $20,717.53 for medical expenses | AHCA: settlement sheet shows $120,000 to ERISA + $20,717.53 to Medicaid = $140,717.53 for medical expenses, entitling full lien reimbursement | Reversed: ALJ erred to treat ERISA payment as allocation to medical expenses; ERISA reimbursements can be paid from any portion of a settlement and do not prove allocation |
| Whether Appellant met Wos/Ahlborn burden to rebut statutory formula by clear and convincing evidence | Mobley: demonstrated lesser portion of recovery allocated to medical expenses (3.3%) | AHCA: statutory formula (§ 409.910(11)(f)) yields an amount ≥ lien; Appellant failed to prove otherwise by clear and convincing evidence | Remanded for ALJ to reconsider without treating ERISA payment as medical expense allocation; determine if Mobley proved a lesser allocation by clear and convincing evidence |
Key Cases Cited
- Arkansas Dep’t of Health & Human Servs. v. Ahlborn, 547 U.S. 268 (2006) (Medicaid may only recover portion of settlement allocated to medical expenses)
- Wos v. E.M.A., 568 U.S. 627 (2013) (beneficiary must have opportunity to show party allocation to medical expenses is less than state’s lien)
- Harrell v. State, 143 So.3d 478 (Fla. 1st DCA 2014) (plaintiff may seek reduction of Medicaid lien by proving allocation evidence)
- Zurich Am. Ins. Co. v. O’Hara, 604 F.3d 1232 (11th Cir. 2010) (ERISA plan reimbursement may be taken from any portion of a settlement)
- Moreland ex rel. Moreland v. Agency for Persons with Disabilities, 19 So.3d 1009 (Fla. 1st DCA 2009) (standard of review: ALJ findings reviewed for competent, substantial evidence)