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Exclusion from Coverage of Claims Brought By or On Behalf of a Governmental Entity Applied to a Qui Tam Case Brought by a Private Party Pursuant to the Federal and State False Claims Acts Re: Medicare and Medicaid Over-Billing—the Private Party (“Relator”) Is Bringing the Action On Behalf of the Government, Which Is the Real Party In Interest

The First Department determined that the insurer’s motion for a declaration it was not obligated to pay for defendant’s defense in a lawsuit under the Federal False Claim Act alleging excessive Medicare and Medicaid billing.  As allowed under the Act, the suit was brought by a private party, called a “relator.”  The policy excluded coverage for any and claim “Brought by or on behalf of the Federal Trade Commission, the Federal Communications Commission, or any federal, state, local or foreign governmental entity, in such entity’s regulatory or official capacity.”  Supreme Court determined the exclusion did not apply because the suit was brought by a private party.  However, pursuant to the terms of the False Claim Act, the action brought on behalf of the government by the relator and the government is the real party in interest:

An action brought under the False Claims Act may be commenced in one of two ways. First, the federal government itself may bring a civil action against a defendant (31 USC § 3730[a]). Second, as is the case here, a private person, or “relator” may bring a qui tam action “for the person and for the United States Government,” against the defendant, “in the name of the Government” (id. at [b][1]). Under such circumstances, the government may elect to intervene, and if it recovers a judgment, the relator receives a percentage of the award (id. at [d][1]). If the government declines to intervene, as in the case here, the relator may pursue the action and may receive as much as 30 percent of any judgment rendered (see id. at [d][2]).

While relators indisputably have a stake in the outcome of False Claims Act qui tam cases that they initiate, “the Government remains the real party in interest in any such action” … . As the Second Circuit has explained:

“All of the acts that make a person liable under [the False Claims Act] focus on the use of fraud to secure payment from the government. It is the government that has been injured by the presentation of such claims; it is in the government’s name that the action must be brought; it is the government’s injury that provides the measure for the damages that are to be trebled; and it is the government that must receive the lion’s share-at least 70%-of any recovery.” Certain Underwriters at Lloyd’s London Subscribing to Policy No. QK0903325 v Huron Consulting Group, Inc., 2015 NY Slip Op 03608, 1st Dept 4-30-15

 

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