When a traumatic brain injury accident occurs, it is usually the first time that anyone looks at their 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 health and accident insurance 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 rehabilitation services?
Persons with a traumatic brain injury are going to need outpatient rehabilitation services.
Does the health and accident 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 coordinated?
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 brain injury?
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. This policy should be reviewed by your attorney 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 homeowner’s 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.