Paying for Medical Care and Rehabilitation
If a motor vehicle wreck caused your head injury, then most likely there was an automobile liability policy that covered the vehicle that you were in. These policies usually include “medical payments coverage” that will pay your medical bills regardless of who caused the wreck up to a maximum amount. Common limits on this coverage today are $1000, $2500, $10,000, $25,000, and $100,000.
Under coordination of benefit rules, medical bills should first be submitted to this insurance company. In most cases, your own health insurance company will not pay any benefits until after the auto insurance company has paid everything that it is required to pay under the medical payments coverage.
If the car you were in was not your own, then you may also be able to submit a claim to your own insurance company under its “medical pay coverage.” The exact language of your policy will determine whether this is possible. In almost all cases you will not be entitled to collect under your own policy until the limits of the other policy have been exhausted.
Medical payments coverage is generally a good way of getting your bills paid because these policies, unlike health and accident insurance, generally do not contain restrictions on the type of medical expenses that will be covered.
If you were injured in a state that has no fault insurance, then a somewhat different system applies in which you submit your medical bills under the PIP (personal injury protection) coverage of the car in which you were riding.
Health and Accident Insurance, PPO, or HMO Plan
After you have exhausted the limits of the available medical payments insurance, your medical bills will generally be paid under your health and accident, PPO, or HMO plan. Even though your initial bills may be covered by the medical payments coverage of auto policies, you should be sure to comply with any pre-certification and referral requirements of your own plan, otherwise you may find that a substantial portion of your bills are not covered.
Amounts paid out by the medical payments coverage generally are applied against your deductible, co-pay, and any co-insurance requirements of your plan.
All plans will pay only for those services that are considered medically necessary. Generally this means care that is consistent with the diagnosis and care that could not be omitted without adversely affecting the patient’s condition or the quality of the care rendered.
Many of today’s plans contain significant restrictions on paying for services that a person suffering a head injury may require. Some common restrictions or limitations:
- exclusion of or limitation on amount of rehabilitative services such as occupational therapy, physical therapy, speech therapy, and cognitive therapy;
- post acute care;
- skilled nursing care;
- convalescent care;
- custodial care;
- home health care (limits on number of visits or limit on reimbursement per visit);
- exclusion of PET scans as experimental;
- exclusion of the cost of writing a neuropsychological report; and
- outpatient charges.
Make sure that the insurance company, PPO, or HMO does not misinterpret its policy. For example, treatment of emotional and behavioral problems caused by the head injury should not be classified as psychiatric benefits. You will want to work carefully with the hospital worker assigned to obtaining financial benefits from the insurance companies. In many cases you can also benefit by working with an attorney to assure that you get all the benefits to which you are entitled.
Third Party Claims and Subrogation
You should consult a knowledgeable attorney at an early stage if you believe that the wreck was someone else’s fault. Almost all insurance policies contain fine print that requires you to pay back the insurance company out of any money that you receive from the person who caused the wreck. The fine print is valid in some cases and not in others. If your health insurance plan is partially self-funded by your employer, it is very important for you to visit with an attorney early on. These self-funded plans are governed by a complicated federal law known as ERISA.
Nebraska Workers’ Compensation
If you suffer a head injury while performing job duties, then you probably will be eligible for Workers’ Compensation benefits regardless of who caused your injury.
Workers’ Compensation benefits are relatively comprehensive. Your employer is required to pay for your medical treatment provided that you follow special rules on choosing your primary treating doctor and on obtaining referral to specialists.
If you jump through the right hoops, in most cases you will be able to choose your own primary treating doctor. If you do not jump through these hoops, you may end up with a doctor chosen by the workers’ compensation insurance company or you may have to pay some of the bills yourself. If you have any doubt about how to follow these rules, you should seek the help of a knowledgeable attorney.
When your brain has been injured, it is very important that you receive treatment from specialists who thoroughly understand the nature of your brain injury and understand how even a mild injury can significantly interfere with your continued ability to function effectively in life. Referrals to the wrong specialists may lead to your not getting the treatment that you require and to your never receiving the compensation that the law says is due you.
Medicaid is a largely federally-funded program that is administered through the states. It helps pay doctor and hospital bills of disabled persons who do not have significant income or assets. The eligibility requirements for this program are somewhat different in each state. Certain assets such as the home you live in and one car are generally excluded in determining your assets.
Medicaid is a potential source of funding not only for people who do not have resources but also for disabled teenagers who are about to turn 18. Parents may want to consider qualifying their children for these benefits.