CERTAIN HEALTH INSURANCE PLANS ARE ENTITLED TO REIMBURSEMENT OF HEALTH BENEFITS PAID ON YOUR BEHALF
If your health insurance paid for the treatment of your injuries caused by a car accident and you pursue a bodily injury claim with the applicable automobile insurance carrier, your health insurance plan might seek reimbursement of the benefits it paid on your behalf from any settlement proceeds or jury verdict. The ease with which a health plan (“Plan”) might successfully get such reimbursement may depend largely on how the plan is structured. For some health plans, you could argue what Georgia law calls the “made-whole” doctrine. See O.C.G.A. § 33-24-56.1 Under this doctrine, the Plan can seek reimbursement only if you are “made whole” meaning the amount of your recovery exceeds the sum of all economic and noneconomic losses incurred as a result of the injury, exclusive of losses for which reimbursement is sought. For other plans, this doctrine does not apply, making it easier for that plan to seek reimbursement.
HOW DO I KNOW IF THE “MADE-WHOLE” DOCTRINE APPLIES OR NOT?
One type of health plan to which the “made-whole” doctrine may not be applicable is a self-funded employee benefit plan that falls within the Employee Retirement Income Security Act (“ERISA”). You have to scrutinize the relevant documents, including the Plan language, and research to determine whether that Plan is a self-funded ERISA plan or not.
MY HEALTH PLAN SENT ME A LETTER SAYING THEY ARE ENTITLED TO REIMBURSEMENT. SHOULD I BELIEVE THEM?
Some health plans might assert they are entitled to reimbursement when in reality they are not. They might claim they are a self-funded ERISA Plan when they are not. For example, if an ERISA plan does not contain a language specifically denying the “made-whole” doctrine, you could possibly argue for the “made-whole” doctrine.
WHAT HAPPENS IF MY HEALTH PLAN IS ENTITLED TO REIMBURSEMENT?
If your health insurance plan is indeed entitled to reimbursement, that Plan will send you or your attorney a specific amount they are requesting and a breakdown of how they arrived at that specific amount. You or your attorney should carefully look into this, including reviewing your medical records and itemized billing statement, to make sure the requested amount of reimbursement is legitimate. If the amount your plan is requesting is inaccurate, you need to contest this with your Plan. Further, Plans will sometimes accept a request for reduction of the reimbursement due under certain circumstances.
HOW DOES MEDICAL PAYMENTS COVERAGE UNDER MY AUTOMOBILE INSURANCE COME INTO PLAY?
Some health insurance plans have a high deductible. Also, health insurance plans may not cover all of the treatment you get for your injuries. Therefore, under certain circumstances, it may be beneficial for you to have medical payments coverage under your automobile insurance. Your medical payments coverage, if you have one through your personal or resident relative’s automobile insurance, may help cover some of these out-of-pocket expenses.