Health and Accident Insurance
When a traumatic brain injury accident
occurs, it is usually the first time that anyone looks at his or
her health or accident insurance policies. All policies should
be closely examined, particularly for the following items:
What are the limits of the lifetime
benefits? Is there a $1,000,000 lifetime maximum under the
health insurance policy? What is the deductible? Will the policy
pay 100% of each medical bill or only a percentage? Is there a
gap in coverage, so that the first $10,000.00 in medical bills
are excluded? What are the "exclusions" in the policy?
The exclusions are usually printed in fine
print on all insurance policies. There is a saying in insurance
law "What the big print giveth, the small print taketh away."
With respect to exclusions that is true.
Does the policy pay for only hospital
care, or does it pay for care and rehabilitation facilities,
transitional living program, skilled nursing care and long term
care in a nursing facility? What is the definition of
Persons with a traumatic brain injury are
going to need outpatient rehabilitation services.
Does the insurance company have an option of terminating
coverage? Is it the insurance company or their doctor that
determines that a person is no longer making progress as the
result of rehabilitation services? How are the benefits
Typically, insurance policies provide that
health or accident insurance has to be coordinated with any
insurance that you have so that when you have two insurance
policies, which one is responsible?
Bills will be submitted first to the
primary carrier who has to pay the bills according to the
insurance contract. Any remaining bills are forwarded to the
"secondary" insurance carrier. It is often very difficult to
determine which carrier is primary and which is secondary,
especially when there are enormous bills and a traumatic brain
injury: neither insurance company wants to assume
responsibility. In such instances, the assistance of an
experienced attorney is critical.
Is there a major medical carrier, HMO or
some type of private health or accident insurance, which will
pay medical bills if there is a catastrophic injury such as a
As soon as possible after the injury or
illness, you should get a copy of the insurance policy and plan
booklet and find out whether the insurance company will cover
rehabilitation expenses, skilled nursing care, transitional
living programs, etc. Your attorney should review this policy so
that you can make adequate discharge planning decisions and
properly fill out the application and proof of claim forms.
Is there coverage under the homeowner's
insurance policy or an umbrella/excess policy?
Many homeowners' policies provide coverage,
which pay a certain amount of medical bills, regardless of how
the injury occurred, so long as it happened on the premises of
the homeowner. Accordingly, homeowner's insurance policies, and
any excess or umbrella policy should be carefully examined to
determine whether or not there is medical coverage under the
terms and provisions of that particular policy. This needs to be
done promptly because many policies contain language requiring
notice of injury or proof of claim being filed promptly.
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