Health Insurance Reimbursement FAQs

Are you confused and frustrated about health insurance and your personal injury claim? You’re not alone. Many details go into how your health insurance may be reimbursed through the compensation you receive.

Have a question that wasn’t answered here? Ask us now using the form to the right.

Health Insurance Reimbursement

How is health insurance reimbursed from my settlement?

Our goal for each and every client is to maximize the amount put in his or her pocket. Obviously, we must pay for medical expenses incurred as a result of treatment for injuries out of any recovery. However, in the last 5 to 10 years we have seen an explosion in the number of health insurance companies seeking reimbursement from the settlement for medical expenses paid for injuries resulting from the negligence of another party. Whether your health insurance company can obtain reimbursement from your settlement may depend upon the type of policy you have and whether you or your employer provided it and paid for the premiums.

What if I have privately purchased health insurance?

We do not reimburse these plans. If you purchased your health insurance from an agency or carrier, then your health insurance most likely cannot seek reimbursement from your settlement. North Carolina has an anti-subrogation rule that prohibits health insurance companies from obtaining reimbursement when the insured pays for the health insurance. An example is when you buy your own health insurance and pay for the premiums on your own and not through a plan provided by your employer. When we are presented claims from these privately purchased health insurance plans, we simply notify them that they are prohibited from seeking reimbursement and in most cases they withdraw their claims for reimbursement. Again, we do not reimburse these plans.

What is ERISA?

What is ERISA? ERISA is short for the Employee Retirement Income Security Act of 1974. Under this Act, employers are allowed certain federal tax benefits as an incentive to provide benefits to its employees. One benefit many employers provide is health insurance. (We provide health insurance to our employees too but our plan is not self-funded, nor is it an ERISA plan) In many instances, the employer provides the health insurance through a self-funded plan, meaning that the employer funds the plan that pays the claims submitted for medical expenses. These self-funded plans are exempt from the anti-subrogation rule in North Carolina (discussed above) and therefore these plans may seek to recover part or all of any settlement, depending upon the specific language in the plan. We usually find that the plan’s language provides that it may recover all of the money it has paid even if that amount would mean that the injured party gets nothing.

Once we determine that our client’s health insurance plan is protected by ERISA, we research the following important factors:

  1. Who is the real employer?
  2. We request our client to provide us with a copy of her health insurance card.
  3. What is the name of the entity attempting to collect the reimbursement for the health plan? We typically find Rawlings, ACS Recoveries, Ingenix and other collection companies contact our clients on behalf of the plan so we usually deal with one of them during our attempts to negotiate the reimbursement. However, once in a while we find that the employer itself will attempt to collect the monies.
  4. We always research the employer by locating a form 5500 filed by the employer which identifies the type of plan and how it is funded.
  5. We contact the collection agency for the plan and request an itemized listing of medical bills paid so that we can omit any unrelated charges.
  6. At no time do we agree to reimburse the plan even though we attempt to advise of our willingness to negotiate a fair resolution that would our client to receive a fair amount of the recovery.

Note: If the employer or the employer’s health plan purchases health insurance to pay the employee’s medical bills then the plan would not be considered a self-funded plan and it is our opinion that the plan is not allowed to seek reimbursement under North Carolina’s anti-subrogation rule (discussed earlier).

Once it is determined that the employer’s health plan is a self-funded ERISA plan then we do everything possible to negotiate with the plan to work out a fair resolution to the plan’s claims for reimbursement and at the same time allow our client to keep a fair amount of the recovery. This process can be time consuming and very frustrating but we have been very successful in the past on behalf of our clients.

Can my city or county government health insurance Plan be reimbursed?

If your employer is a city or county governmental body, then the health plan provided may or may not have rights of reimbursement. These plans are not protected by ERISA. We investigate the language in these plans and work with them in an effort to resolve these claims in an effort to maximize our client’s recovery and yet resolve the plan’s claim based on equity and fairness to the injured party. Usually these plans are easy to work with in resolving the claim for reimbursement on a fair basis to all parties.

If you have Medicare, Medicaid, VA health insurance, military health insurance (Tricare) or state health insurance, we must reimburse the plans. There are pages on our website that discuss the specifics of reimbursement to these plans.

Have questions about how your medical expenses will be reimbursed if you file a lawsuit? Contact us today to discuss your legal rights and the details of your specific case.

Call 800-525-7111 today or fill out the form at the top of this page to ask your question now.