Health Care Freedom: Personal Injury and your Auto Insurance

 

As we continue to see a growing number of patients in our office, we are often confronted with injuries sustained from auto accidents and patients wanting to make a personal injury claim against either their insurance company or the other parties insurance.  Most of the time, the patient has no idea how a personal injury claim is handled and this can lead to many complications in getting any compensation for care.

 

Most accidents follow similar scenarios.  “I was sitting at a stop light and the guy slid into the back of my car!”, or “I was driving through an intersection and this lady ran the red light and hit me from the side!”  In both cases the drivers exchanged information and left the scene confident that the other was insured.  They get home and started to feel their neck tightening up and called our office for an appointment.  At our office they explain that the other guy is insured and assured them that it would cover any necessary treatment.  Sounds simple enough, the other driver even admitted fault so his insurance should have no problem taking care of you, right?

Unfortunately, the answer is…wrong!  Getting an insurance company to pay for any medical expenses is a long drawn out and complicated process.  You see the insurance company is going to do anything and everything not to pay a claim.  Believe me, I have been to seminars on this.  Their protocol is delay, deny, defend.

 

First you will make a claim and a very nice person, Sam, is assigned your case.  Sam gives you all the feel good information you need to relax and believe your claim is being professionally handled.  He asks you to gather all of the information concerning the accident and any and all treatment you have received.  You spend time and energy doing this and send the information as requested.  Days and possibly weeks go by with no response and so you call to find out what is going on with your case.   You even call Sams extension and ask for him by name.  You’re surprised to find out that Sam is no longer handling your case - it has been re-assigned to a woman named Lupe.  She tells you that she is unaware of any information you have sent and would you please send it again.

This runaround continues until many claimants get frustrated and quit the process.  Those who persist are usually denied for some reason or another.  Insurance companies employ lawyers whose only job is to find out how to deny a claim and then to defend their denial in court if necessary.

 

Sounds pretty hopeless, doesn’t it?  So what is the best way to go about this process?

 

First of all, examine your own auto insurance policy and see if you have medical coverage or “med pay”.  This is coverage for you so you can immediately get the treatment you need with out having to go through the above mentioned process.  Med-pay benefits are paid regardless of who was at fault for the accident.  The policy is just as applicable if the you are struck by another vehicle, strike another vehicle, or are involved in a single vehicle accident.  Your insurance company will address any medical expenses and they will go after the other persons insurance.  It is a good idea to carry at least $5000.00 in med-pay coverage.  The best part about this is that under California law,  it is illegal for your insurance company to increase your rates from utilizing it.  Most insurance salesmen won’t mention it’s availability when you purchase your policy so you have to ask for it specifically and…believe it or not it is not that expensive.  Most people believe they have “full coverage” and that they have done all they can to protect themselves.  Unfortunately, after an accident is the wrong time to find out that your policy does not have med pay.

 

For years, this was all a consumer needed to know about medical payments coverage.  However, as a natural progression of the insurance industry’s desire to maximize profits, the availability of benefits has decreased.  Further down in this article under Types of Medical Payments Coverage, we will examine the degree of benefits available to the consumer, and have listed some common coverage, in decreasing order of  benefits, ie. best to worst.

 

If you you don’t have med pay and are injured in an accident,  you may be smart to get a lawyer for yourself.  They know how the system works and can guide you through the process.  A court battle is expensive for the insurance company and many times they will settle the claim if you are well represented.  Going into this process unrepresented is like sheep being thrown to the wolves - guess who is who.  Most personal injury attorneys will review your case and  let you know if it is worth pursuing and they will not charge you unless they get a settlement for you.  Of course all personal injury attorneys are not as scrupulous as their personalities may seem.  What?!  An unethical lawyer you say?  Yes, it’s true, some lawyers are very adept at lining their pockets from your misfortune.  Of course there are good attorneys as well.  We can recommend someone to you.  We can tell you who has treated our patients well in the past and also has worked with us as the doctor in the best interest of the patient.  If this is the way you are going to proceed, just one more bit of advice.  Get your attorney going on your case ASAP.  This will give you the best chance at a favorable resolution.

 

 

 

“Non-reimbursable. Non-excess Med-pay” is coverage that many refer to as the last “true med-pay”.  There is no repayment obligation by you, and the applicability of coverage is independent of your health insurance benefits.  It is the most expensive of the medical payments coverage, but the added cost is not by any means substantial.  It is not uncommon for the coverage to cost $5-10 per $1000 of coverage over a six month period.  This is the type of insurance you should have and what I recommend as a health care provider. (BEST!)

 

 ”Reimbursable Med-pay” marks the first in the deviation from the type of Med-pay that was typically provided, and is one level lower on the scale of desired coverage.  The reimbursement is described by many names, such as “Third Party Liability”, “TPL”, “subrogation” or “contractual reimbursement”.  All of these names have been used interchangeably to detail the concept that the original payor of the bills is due to receive a refund of amounts paid from settlement or judgement against the responsible party, due to the fact that its policyholder was not a fault for the incident.  The way this typically works, is that the med-pay insurer pays the bills as deemed reasonable and necessary, up to the limits of the coverage.  The insurer then has a claim against the settlement proceeds, or award of judgement, pertaining to the case of the policy holder.  Upon settlement or judgement, the policyholder (you) is required to pay the first funds of the settlement back to the payor of the med-pay benefits.

 

“Excess Med-pay” is the first in a series of coverage that many consumer groups feel represents illusory coverage.  “Excess” refers to amounts of medical care that exceed that which your health insurance will cover.  Because of the status of the law, many carriers are refusing to consider billing above any contractual rate between the facility rendering care, and the health insurer.  So, in essence, if you have health insurance and the facility is contracted with the health insurer, there cannot be any excess. So therefore you have no med-pay, although you are paying for it.  Most excess coverage also carries a reimbursement obligation,  therefore, in the event the carrier does pay anything, they receive the amounts they paid as reimbursements.  Further complicating this coverage, and giving further support for the allegations that the coverage is illusory, is the fact that without health insurance, many policies are subject to a deductible, often times 40% of the coverage amount. 

 

“Modified, or Coordinated Med-pay” further represents coverage which may be classified as illusory.  The “Modification” or “Coordination” is between the health insurer and med-pay carrier, thus acting as excess med-pay.  There is one little difference, however, in that it only pays a percentage of the excess amounts after you first pay a deductible.  The same problems persist as with “excess” coverage, in that if there is health insurance the insurer may refuse to honor any amounts in excess of what was paid by the health insurer. (Worst!)

 

A final word about insurance companies.  insurance companies have been known to arbitrarily change your coverage from “Non-reimbursable” to “Reimbursable” and from “Non-excess” to “Excess”.  You should take the time to review any notices sent to you by your insurer which reflect “changes to your automobile policy” and immediately reject any non-requested changes.