Will Health Insurance Pay for my Medical Care?

Most people who are injured due to the negligence of another have some form of medical or health insurance already in place. This may be private health insurance, an employer-provided group health plan, Medicare, Medicaid, a State Employee Health Plan, or any of the medical insurance plans offered to employees of the federal government or members of our Armed Services.

The initial determination of whether an injured victim’s health insurance will pay for medical care will depend upon whether the victim’s injury occurred on-the-job or not. If the injury did not occur on the job (and therefore cannot be a workers’ compensation injury) then the victim’s health insurance should pay for all injury-related claims. North Carolina and South Carolina are pure liability States, which means that the liability insurers for individuals or businesses who cause injury will not pay for medical expenses as they are incurred. Rather, these liability insurers will reimburse injured victims for the cost of medical care and services incurred. These liability insurers, however, will not make such payment or reimbursements unless the injured victim signs a legally-binding document that releases the individual or business who caused the injury from any further liability. For that reason, settlements or jury verdicts that reimburse an injured victim for medical care and expenses incurred may not happen for months or even years after the medical treatment resulting in the expense is received. Medical providers, however, are often not willing to wait months or years for payment. These medical providers may send an injured victim to collections if the bill is unpaid. It is important to recognize that medical providers have no direct cause of action against an individual or business who causes injury, and so medical providers have no recourse to get payment from those injury-causing individuals or businesses. For this reason, it is important that injured victims first look to their own health insurance for coverage of injury-related medical expenses. At a later point in time recovery can be obtained from the appropriate liability insurer in order to be reimbursed for all expenses paid (both those paid by a health insurer, as well as the victim’s own out-of-pocket expenses) for medical care required.

When a person suffers an injury while not on-the-job, the person’s health insurance plan may have a right to be reimbursed out of the proceeds of any recovery that person makes from the liable third-party. It is important to consult a lawyer to understand what your rights and obligations may be in this regard.

If a person suffers an injury while on-the-job, and the other requirements for a workers’ compensation claim are met, the injury victim’s health insurance may not pay for medical expenses. Many (but not all) health insurance plans have a specific exclusion for coverage of medical expenses associated with workplace injuries that are covered by workers’ compensation. Although these health insurance plans may not cover medical expenses if the workers’ compensation claim is accepted, the workers’ compensation insurer will still be liable for payment of such medical expenses. In such circumstances, the injured victim will not be responsible for the payment of out-of-pocket costs such as deductibles and co-payments. Alternatively, not all on-the-job injuries are covered by workers’ compensation or accepted by the workers’ compensation insurer (even if they should legitimately be covered). In such circumstances, if the workers’ compensation insurer denies coverage, an injured victim’s health insurance should step in and provide coverage.