The Quick Answer
Oregon Injury Claims and Health Insurance
Whether your health insurer gets involved with your injury claim depends on whether there is other insurance that is responsible to cover your medical expenses, and if so, the amount of available coverage. This is because your health insurance will exclude coverage where another insurance is involved, and is in the "front of the line" for covering medical expenses. The insurance company at the front of the line to pay medical expenses is considered "primary." Here are a few examples:
If you are injured in an auto collision in Oregon, and the car is an Oregon insured car, then you have no fault medical coverage under the auto policy. That coverage is first in line to pay medical benefits. However, an Oregon driver need only carry $15,000.00 in coverage for medical expenses, so if you are seriously injured, that coverage will be paid out, or "exhausted," leaving you with a lot of unpaid medical bills.
You may have been injured on someone else's property, and in a lot of cases, homeowner and business policies offer a "no-fault" medical coverage that pays up to a certain amount of medical expense, regardless of fault. After that coverage is exhausted, you must look to your health insurer to cover medical bills.
How Health Insurers Protect Themselves
Most health insurance is regulated by federal statute, and that statute gives the health insurer a lot of room to write the health plan. Health insurers will exclude coverage for injuries suffered in an auto collision where there is health coverage in the auto policy, or where the injury was caused by the fault of some other person. The health insurer scans your medical records to see if there is a possible injury claim against an at fault party. If it picks up the right terms (think "car wreck," or "fall"), then it sends you a questionnaire to find out if you are planning to make a claim. Under the health plan terms, you must fill out the form, and if you do intend to pursue a claim, the health plan will only pay accident related medical expenses if you agree to reimburse the health plan for the medical bills it paid out of any money you recover from the at fault party or their insurer.
In an auto injury claim, you will have to provide the health plan proof that your auto policy has paid out all available no fault medical benefits.
Paying Back the Health Plan
Some health plans expect you to pay back every penny in medical benefits it paid, regardless of the amount you recover from the at fault insurer. Some health plans even argue that it can deny future accident related medical expenses up to the amount of your overall settlement. Some health plans will negotiate the reimbursement claim while agreeing to cover future care. The law is always changing in this area.
If you do not pay back your health plan, it could file a lawsuit against you to recover the benefits it paid, and attorney fees.
Medicare, like any other health plan, will seek reimbursement for any accident related medical benefits. However, Medicare is a part of the federal government, and has its own rules for recovering the medical expenses it paid for injury related care. If you do not reimburse Medicare, it can also file a lawsuit against you, and can claim three times the amount of injury related medical benefits it provided.
If you have an Oregon injury claim and have questions about medical bills or health insurance, contact us. We help people through these issues every day.