What if my health plan pays for some of my medical care from my injury claim?

If you are injured in Oregon or Washington, and you have a claim against a responsible party, your health insurance may be called upon to pay for some of the medical care required to treat your injuries. Depending upon the type of health insurance you carry, you may have to reimburse your health plan for some or all of the benefits it provided to your doctors.

Health insurance comes in many forms. We use the term "health insurance" and "health plan", but they mean the same thing.  Most health plans will exclude coverage for treatment related to injury sustained as a result of another person’s careless behavior. The reasoning is that the careless person's should pay the medical bill. However, many of these health plans will make payments if you sign an agreement to reimburse the health plan out of any recovery you make from the responsible party.  This is why you need to read these agreements carefully before you sign.

An illustration may be helpful. Let’s say you are involved in a motor vehicle collision, and you sustained serious injuries. You may have medical coverage in your automobile policy, but with serious injuries, that coverage may be “exhausted,” which means that you have used all of the available benefits. If you have a health plan, it will take over paying your medical expenses, but only if you agree that if you make a settlement against the responsible party, you will reimburse your health plan for the value of benefits it provided to your health care providers.

This is similar to the agreement you have with your own auto insurance when it provides personal injury protection benefits. However, problems can crop up if the careless party does not have enough coverage to cover all of your medical bills, including those bills your health plan covered.  Also, there may be a disagreement whether the careless party was 100% responsible for your injury, and there could even be an issue about whether the medical care that you received was related to the accident or collision.

Some health plans will allow a discount or reduction of the amount you must reimburse to share in attorney fees, account for the other party's fault, or even to make sure you are fairly compensated. Others will not. There are some health plans that will consider the total settlement or recovery amount as subject to reimbursement, and may exclude any future accident related care up to the amount of your overall settlement, regardless of whether it was allocated to attorney fees, costs, or lost wages.

If you have a serious injury claim where your health plan is involved, call us at 503-325-8600 if you have questions. We deal with these issues every day.