Each type of injury is different and how you pay for medical treatment varies depending on the type of injury and statutory rights and obligations based on the type of injury. Motor Vehicle injuries, Medical Malpractice medical expense, and Worker's Compensation injuries each have statutory regulations which dictate your rights to recover medical expense losses. Even in those cases such as slip and fall injuries or non statutory regulated claims there are various laws and case law that restrict what you can recover and what you may not have to pay back. An experienced personal injury attorney such as the lawyers in our firm can help you navigate your rights of recovery and your responsibilities to make sure you do not get stuck repaying health insurer payments from a settlement or verdict unexpectedly.
Auto cases are a clear example of a statutory scheme that seems to make no sense initially. If you get into a car accident and it is not your fault, YOUR car insurance is going to pay your initial medical bills and perhaps all of them. You are saying to yourself, "WHAT?, why is insurer paying when it is not my fault?" It wasn't always this way. Before 1974 if you were in a car accident and it was not your fault your auto insurer did not pay your bills. You paid your own bills or your health insurer paid some of the bills and you paid deductibles and co-pays. If you could prove negligence against the other driver, then at the end of the case you could present your out of pocket expenses and the amount your health insurer paid for the medical treatment. You would then pay the health insurer the amount you recovered for the medical bills it paid.
The problem was that not everyone had health insurance, or the deductibles and co-pays were high and there was an awful lot of out of pocket money spent by the injured party. The responsible negligent motorist had insurance and except in the rarest of circumstances refused to pay until it had to. The theory being as long as an insurer was paying the longer the patient would treat. Sometimes the amount of liability insurance was not enough to pay for all of the medical bills. It was a real mess. In 1974 the concept of No-Fault Insurance was sweeping the country. This is where as part of your automobile insurance you were required to buy No-Fault benefits which would pay all of your reasonable, necessary and related automobile caused medical expenses, regardless of who was at fault in an accident. Even more amazingly, if you had private health insurance an injured party could require his private insurer to pay the sma medical bill which was paid for by the auto insurer and pocket the double payment since it was a "collateral source" and legal to do so.
This universal unlimited medical expense plan was in place for about 10 years. It became way too expensive, especially for the catastrophically injured motorist who may have paid $100 for No Fault medical benefits, but who needed millions of dollars of future care. So in 1984 the law was passed which limited No-Fault mandatory medical coverage to $15,000.00 with options to buy more coverage. The theory being that this would allow the at fault motorist and the innocent motorist to have a guaranteed amount of coverage. Once exhausted, then the private or public health insurer couls take over and pay the bills. If at the end someone else was responsible then those bills paid over and above the First Party Benefit could recover from the negligent party and pay back the health insurer as was done before.
However, this too became too expensive according to insurers. So in 1993 the auto insurance industry convinced the Pennsylvania Legislature to adopt our current Motor Vehicle Financial Responsibility Law (MVFRL) which was a hybrid fault/no fault scheme. Every driver is required to have a minimum coverage of First Party Medical Benefits of at least $5,000.00. Motorist can obtain more coverage if he or she sees fit. If a motorist bought more coverage then that coverage was first in line to pay for medical bills related to the car accident. Whenever the amount of insurance chosen ran out, it would then be up to the motorist to have private health insurance, or public (welfare-Medicaid, or Medicare coverage) The difference was that the private insurers were barred from seeking recovery for the amount it paid on account of automobile caused injuries, however, public payors such as Medicaid and Medicare were still required to be reimbursed.
Soon after certain health plans for employers and or unions started to seek reimbursement on the basis that the Pennsylvania MVFRL did not apply to them because the health benefits it supplied were from a plan which is a federally approved plan under the Employee Retirement Income Security Act (ERISA) and that state law did not apply to federally approved plans. After many years of tortured litigation it became the law of the land that ERISA and Union Plans were exempt from state law and thus if the medical bills from a car accident were paid by an ERISA plan after the automobile first party medical insurance exhausted, then that plan was entitled to be reimbursed much like Medicaid and medicare in accordance with the plan language. The problem with that set up is that at times the ERISA plan will not negotiate or take less than the full amount and will not even give the injured party credit for having to hire an attorney. This is why you need an experienced automobile injury lawyer to navigate these tricky waters of ERISA law regulations. Our firm regularly deals with and maximizes the recovery to the injured party by negotiating with ERISA carriers and making sure the injured party is treated as fairly as possible.
This is very much like the automobile cases. After the MCARE Act of 2002 the recovery of past medical bills eliminated the right to recover for medical bills paid by health insurers, except for ERISA Insurers, Union Plans and Public Health payors. Further future medical care after a verdict is doled out in yearly installments as the MCARE law requires and needs to account for how it is paid. Again, the complexity of this law requiring you to have an attorney who is experience in handling and proving medical malpractice claims and the rights of injured patients. Future Medical Bill Claims is even more complex than past medical expense claims and only an experienced medical malpractice attorney can guide you to protect your rights in claiming these benefits
In many ways these are the easiest types of cases to deal with once the case is being litigated, tried, or settled as far as payment of injury related medical expense. The injured parties health insurance for the most part pays for the treatment and gets reimbursed for what it paid when the case is settled or the injured party won a verdict. There are wrinkles in the payment schemes.
Most liability insurance policies covering a landowner, homeowner, business have a clause which is called a "MED-PAY" clause. This clause is similar to a no-fault clause, but paid for by the person/entity who is likely to be sued. The clause usually states that the policyholder who is insuring the business/property is having a maximum amount of money to pay medical bills for a fixed period of time regardless of fault. There is a belief that many people are not looking to sue, and only want to get medical bills paid. The belief by insurers is if it has a policy which will pay a limited amount of medical bills (say $1,000.00) because of an injury on the insured property and the medical bill is submitted in a set time frame (the first 180 days, first year, first two years, etc.) then the payment without an admission of fault will avoid small nuisance law suits. It is probably true. Many times these liability carriers will pay and then have to defend suit anyway, but it gets a credit for what it has already paid. It is important for your attorney to explore if med pay is available. Not every insurer provides the same.
In addition if you are billed $500 for a test or a procedure and your health insurer paid the UCR (usual, customary, reasonable) amount agreed to by the health insurer in advance of the treatment by virtue of the provider agreement to accept UCR, then you cannot be balance billed unless it is for a deductible or co-pay.
If you are injured while working, even if in a motor vehicle, your employer's workers' compensation carrier is required to pay your bills in accordance with a payment structure which is tied to the prevailing Medicare rates for treatment. Providers are required to accept this payment with no balance billing. However, your workers' compensation carrier has to have accepted or acknowledged the claim and agreed to pay the medicals. If there is a refusal to pay the bills then you need to see an experience attorney in these matters to file a claim. Click here to read more about Workers Compensation.