Do private health plans get involved with Oregon or Washington auto injury cases?

Regardless of where you live, or where your auto collision occurred, if you have private health insurance, it will possibly be involved with your case.  Let's get some background information first, and then address the question.

Private Health Insurance

Most private health insurance coverage is not truly "insurance," but instead a "health plan."  This is especially true if you have health coverage through your work.  Health plans are governed by a federal statute called the Employment Retirement Income Security Act, also called "ERISA."  The ERISA is a federal law, and generally, the federal statute gives the health plan authors a lot of discretion in how they write the plan.  That has likely changed somewhat with the Affordable Heath Care Act, but the people that run your health plan will still have a lot of leeway in how they manage an employer sponsored plan.

Auto Injury and Other "Third Party" Claims

If you have been injured in a auto collision, or if someone's negligence causes you an injury, there may already be coverage for your medical care, and depending on the extent of your injuries, your health care plan may or may not get involved with your case.  In Oregon, you will have medical coverage on your auto policy to pay your medical bills, but the coverage is limited.  In Washington, medical coverage is optional, so you may or may not have medical coverage. 

If you were injured on someone else's property due to their negligence, you may have a claim against the property owner if the property owner was careless, and that carelessness caused your injuries.  However, even if you do not have a claim, the property owner may have "no fault" medical coverage to address medical expenses.

Where you make a claim that the other party is negligent or careless, you are making a "third party" claim.  Included in such a claim is a claim for your medical expenses.

Private Health Plans and Third Party Claims

Your private health care plan will not get involved if you have other medical coverage, for example, in  your auto policy, and that coverage is sufficient to cover all your medical bills.  Or, if you are injured on another's property, and medical coverage is available to pay all medical expenses, then the private health plan will not get involved.  However, where you have serious injuries, or require medical care that will cost more than what the auto coverage or "no fault" medical coverage on a property owner's insurance offers, then the private health plan will be a factor in your case.

Private health plans generally do not cover medical expenses where you are making a third party claim, but will often agree to provide coverage if you promise to reimburse the private health plan from any settlement or recovery that you make against the third party. The health plan may send you a questionnaire asking about the details of the third party claim.  If you are making the claim, you complete the form and send it back.  The health plan will then have you enter into an agreement that you will reimburse the health plan the cost of any benefits that it provided.

In some cases, this is not a problem.  However, you should have a clear understanding of the plan's reimbursement rights under the plan language.  Some plans will expect that you fully reimburse the plan for all of your past medical expenses that were covered, and even into the future.  Some plans will not allow any discount to compensate you for your efforts in recovering money to reimburse the plan for what it paid in medical benefits.

There is a lot of litigation over how much to reimburse a health plan, or whether it should be reimbursed at all.  There are also questions about whether state statutes that would act to limit how much a health care plan can recover are applicable, given that this is a federally regulated area.  This is a quickly changing area of the law.

So, if you have been in a serious accident, and your health care plan is sending you forms, give us a call at 503-325-8600.  We can answer your questions, and even if it is not a case we can handle, we can point you to the right attorney for the job.