Understanding the Personal Injury Settlements and Health Insurance Claims

There is a good chance that other people will try to take your personal injury settlement. One of the most surprising things is that your company may pay your claims for health insurance. We’ll be discussing how these claims can arise and the simple ways to resolve them.

How the Subrogation Process Workes

When discussing personal injury settlements, you may hear the term “subrogation”. Subrogation and reimbursement claims can be technically different. The outcomes of your settlement are the same for purposes of resolving claims. We will discuss the usual practice of referring the claims of the health plan as subrogation claims in the following discussion.

Subrogation Notice Letters

Your insurance company will likely send you a letter asking for details about an accident. The letter will ask you if the accident was work-related, whether a third party was involved, as well as the name of the insurance adjuster responsible for the at-fault party.

It will ask for information regarding whether you have retained an attorney and, if so, their contact information. The correspondence or form will also remind you of language in your insurance policy which states that the insurance company has the right to all reimbursements for any personal injury settlement you receive, regardless of whether it is a settlement or verdict.

The purpose of subrogation

Subrogation notice letters are based on the idea that your health insurance will protect you in the event of an injury or illness. Because the key issues of liability, damages and indemnity have not been resolved in your personal injury case, your health insurance will cover your medical expenses if a third person injures. The health insurance carrier will ultimately assert that the at fault party’s liability policy should cover your medical expenses. It will also assert its rights for reimbursement for expenses it paid in connection to your treatment.

Get a copy of the policy

You must ask the administrator for a copy your insurance policy. In summary plan booklets, which describe plan benefits, the plan administrator will be identified. Penalties may apply to plan administrators who fail to provide plan information.

You must first read the policy language to understand which rights your insurance carrier may claim. You must check the policy language to determine if it allows subrogation. Federal law states that if the policy doesn’t contain such language, the carrier might not be able to sue you for damages.

Review the state insurance laws

Subrogation may be prohibited or restricted by state law for health insurance carriers. Ask an attorney or check with the insurance department of your state to determine if there are any restrictions on subrogation for personal injury settlements.

Check to see if your employer has a policy that covers medical claims

We have only ever mentioned health insurance policies up to now. Your company might self-insure your employees’ health benefits if you work in a large organization.

This distinction is crucial because federal law can override state law if the plan’s self-insured. This means that even though state law states that insurers cannot assert a claim on your personal injuries settlement, the state law might not apply to your employer if it self-insures its healthcare plan.

This information should be included in the summary booklet that explains the plan benefits. Self-insured plans are usually governed by the Employee Retirement income Security Act of 1974, or “ERISA”. You can find more information on these plans at the Employee Benefits Safety Administration website.

Request the Elimination of Unrelated Claims

The health plan may not reimburse you for medical expenses that were not related to the accident. Request a detailed list of the medical benefits that the claims administrator has listed as being related to the accident. Read them carefully.

Request a reduction in attorney’s fees

If an attorney has been retained to represent your case and the health plan doesn’t state otherwise, you might be eligible to request a reduction in attorney’s fees. This means that if an attorney charges 33 percent, you can ask for a reduction in your reimbursement claim.

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