QuestionHello:
I have been to my HMO doctor and physical therapy with co-pay of only $15 each visit. How would the adjuster evaluate total medical expenses for final bodily injury settlement offer to me?
Thank you,,,
AnswerHi Mass,
One of the challenges of personal injury insurance law is that some very simple topics seem to have so many different and complex possibilities. That is the case here, inasmuch as your question is framed by the issues of valuation AND SUBROGATON (see below for a page explaining subrogation). There are three aspects to your question, and only the first one of them can be answered by me, since I do not know either your state or your subrogation rights of your insurer/HMO.
Here are the three aspects I see in your situation:
#1. How will the adjuster evaluate my claim if she uses a formula approach based upon medical expenses?
#2. What is the subrogation policy of my HMO or insurer?
#3. Should I ask my HMO to submit a letter with the market value of services rendered and will that trigger a subrogation claim that maybe they are not otherwise going to make?
Now, Mass, by my identification of these issues, you can see how the problem shakes out. Let’s take them one at a time.
Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
#1. How will the adjuster evaluate my claim if she uses a formula approach based upon medical expenses?
In truth, a formula-based valuation is a myth these days. Your adversary will evaluate your claim based upon the quantity and quality of medical care that she believes is reasonable and necessary as a result of the accident caused by her insured. Hence, strict dollar value is not so important as quality of content of the medical records.
Hence, you might consider using a narrative report if your HMO records are not in typewritten narrative format. Insurance adjusters like http://iwww.settlementcentral.com/page8003.htm narrative reports since it makes their job easier than sorting through hen-scratched pen and ink entries.
In some states with subrogation restrictions (see below for a link to a subrogation page) that favor the injured victim, you CANNOT submit your claim for total medical costs: instead, in these (few) states they just allow you to submit the deductible that you had to pay. This is because since they restrict subrogation, you would be getting paid double if you were allowed to claim that portion of the medical costs paid by your insurer and then not have to pay it back to them.
Having said all of that, when I submit a demand letter, I STILL TRY TO PUT IN AS HIGH A VALUE ON MEDICAL CARE AS POSSIBLE. It is going to inure to your benefit in one way or another if you get to show $5,000 in medicals versus just $1,000. Thus, I either get the actual value of the services rendered from the provider, or I make it up based upon the market value, and let the adjuster challenge it.
Part of the “why” of making up the figures will be explained below, when we ask whether or not it is wise to awaken a sleeping HMO subrogation unit by asking for a letter giving the value of services.
I am in a better position than you to make up the fair market value of services since Dr. Settlement has years of personal injury claims experience. But if I were in your place and I wanted to create the value of services rendered, I would try something with a bit of authority, such as asking your state university medical department or asking your congressional office to steer you to a source of fair market value of services as determined by Medicare.
That way you can support your fair market valuation of services with an authoritative source.
Xxxxxxxxxxxxxxxxxxxxxxxxxx
#2. What is the subrogation policy of my HMO or insurer?
Much of this hiding around has to do with trying to avoid or defend against a subrogation claim from your own insurers. Insurance subrogation http://www.settlementcentral.com/page0459.htm in bodily injury insurance claims is an important consideration in putting together your demand package. YOU MUST KNOW WHAT YOUR INSURER IS PLANNING TO DO.
Some HMO subrogation departments NEVER get the claim in the first place since the file or medical record was not flagged as a third party liability accident. Usually that information is on the check-in sheet the patient fills out. But, I am just letting you know that for some reason many subrogation claims are missed by HMOs.
If you do know that your insurers are planning to make a subrogation claim, GET IN THERE RIGHT AWAY and dispute as much as you can. Be sure to eliminate from their subrogation claim any treatment costs that were NOT associated with the accident. That means all other medical care must be excluded from the subrogation claim (i.e. broken leg from skiing).
Xxxxxxxxxxxxxxxxxxxxxxxxxxxxx
#3. Should I ask my HMO to submit a letter with the market value of services rendered and will that trigger a subrogation claim that maybe they are not otherwise going to make?
Well, if you know that your company is going to make a claim for subrogation, then your problem is solved inasmuch as they will prepare the claim using actual fair market values for the services rendered. Hence, you will add your deductible to that subrogation total and you are set.
The tougher question is whether you want to kick a sleeping dog. If the HMO is not planning to make a subrogation claim because of THEIR OWN INCOMPETENCE maybe you should alert them to make a claim against your award. Or maybe NOT!
I do not get in to advising people to avoid their civic and legal duties, but I will just tell you that there are many times when HMOs have failed to make a subrogation claim and if they had been altered, then they would have jumped all over it.
Hence, in that case, most wise claimants will not kick the sleeping dog and instead they will work with the third party adjuster to come up with satisfactory agreed values for the services rendered.
OK, Mass, that about covers it for now. I trust my time here has produced some information that has been of value to you, and thus I would respectfully request that you take the time to locate the FEEDBACK FORM on this site and leave some feedback for me.
Best Wishes,
Dr. Settlement, J.D. (Juris Doctor)
http://www.SettlementCentral.Com
P.S. I apologize for the delay in answering you, but the flu laid me low for this past week, and I do not wish that on anyone as it was debilitating.
