Personal Injury Claims and Health Plans: Issues of Reimbursement

The Basics

If someone's carelessness causes you injury, you have a claim against that person to recover for the harm you suffered and your losses.  Often, the careless person has insurance that will cover the claim through "liability" coverage.  These claims take time, especially when your injury is serious, and requires significant medical care.  In many cases, liability insurers are not obligated to pay your medical expenses as they are incurred, so you will have to look elsewhere to get your medical expenses covered.

In an auto injury claim, there is coverage for medical expenses in your own policy, regardless of fault.  This is called "personal injury protection" or "PIP."  If you are insured in Oregon, its mandatory.  If you are insured in Washington, insurers must offer the coverage, but you do not have to accept it.

Sometimes, your private health plan or even Medicare will get involved in paying for medical care.  In auto injury claims, this happens when you have used up all of your PIP medical benefits are "used up," or exhausted.  With other kinds of claims, like an injury due to a dangerous condition on someone else's property, your health plan will step in right away to pay medical expenses.

So How Does This Affect Your Claim?

A good starting point is to accept the fact that you and your health plan or PIP carrier are in the same legal "boat."  Each of you have suffered a loss.  You have suffered a loss of your health, and you may have been disabled from your work, and suffered loss of income.  Your insurer has suffered a loss too, but it's only a business loss.  The law allows your health plan to get back what it had to pay for accident related medical benefits.

How Does It Work?

Most health plans are governed by a federal statute that give the health insurer a lot of discretion on what it can include in its plan language.  This includes requirements that you reimburse the health plan for accident related medical expenses if you recovery compensation from the careless person's insurance company.  If you do not, the health plan may be able to file a lawsuit against you to recover the reimbursement, and could also ask for its attorney fees!  So, before you resolve your claim, you need to know what your health plan says about reimbursement.

When we work with a client whose health plan has paid accident related expenses, we often ask for plan provision or summary that sets out the right to seek reimbursement, and make sure we have a ledger showing all the expenses the health plan is claiming for reimbursement.  Sometimes, health plans include unrelated care in its claim for benefits.  We also negotiate reimbursements, arguing that but for our efforts in securing compensation, the health plan would be left empty handed.

Some health plans are even more aggressive in that they will exclude future accident related care if their plan member (the injured person), recovered more than their medical expenses.  We have seen plan language that allows the plan to deny future care coverage up to the amount of our client's total settlement.  Whether this is actually legal is an ongoing issue, and court cases on this issue will often change the law.

How We Help

Many of our clients come to us with clear liability cases involving serious harm.  Our focus is not so much on proving fault or responsibility, but documenting the full extent of the losses and harms, handling reimbursement claims, and making sure our client is in the best position possible to move forward from a life changing injury.


Contact us with your questions to know where you stand on your claim, or check out our free guides and other helpful articles.

Joe Di Bartolomeo
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Top-rated Personal Injury Lawyer Helping Oregon and Washington Families