If you’ve been involved in a Virginia accident, you need to know about health insurance reimbursements. If you’re lucky enough to have health insurance, you’re very fortunate. Many Americans have no coverage, and accident injuries can lead to devastation, both physically and financially. However, if your health insurance plan paid for your medical bills, you may be required to reimburse the Plain if you’re successful with your Virginia Accident Case.
Well, that’s not fair. Why did I even get health insurance?
I understand this sentiment. Here you are, having paid hundreds of dollars for health insurance premiums every month, and now you may have to reimburse your Plan for paid medical bills. Keep in mind, however, there’s never any guarantee that you’ll make money in your accident case. Indeed, under Virginia’s Contributory Negligence laws and other tactics taken by insurance companies, Virginia accident claims are difficult.
If you have health insurance, you can at least be confident that many (if not all) of your medical bills get paid regardless of the outcome of your injury case. What’s more, you have access to care for your injuries. Without health insurance, you wouldn’t be able to get the treatment you need to get better.
As discussed below, you also get the benefit of the health insurance discount.
How much money do I have to pay back? (The health insurance discount).
If you look at your health insurance Explanation of Benefits, you’ll notice that the provider billed one amount, and your Plan paid a different “adjusted” amount. It’s this adjusted amount that (if required) you’ll have to reimburse.
Virginia applies something called the Anti-Subrogation Rule. Under that Rule, a negligent party doesn’t get the benefit of you having health insurance. So, when you pursue your accident claim, you will claim for the ENTIRE medical bill, plus pain, suffering, inconvenience, lost wages and any other claim applicable. If you must reimburse your Plan, it will be at the adjusted amount. Given that, if successful in your accident claim, you should still see proceeds in your pocket.
How do I know if I have to reimburse my Plan?
To be clear, not every health insurer has a right to reimbursement. Indeed, under Virginia’s Anti-Subrogation rules, for many private health insurance policies written under Virginia law, the Plans are barred from seeking reimbursement.
However, there are many types of Plans where this Rule doesn’t apply. Below is a discussion of a few categories of Plans. To be clear, you need to speak with your attorney directly to determine whether health insurance reimbursement will apply in your case.
NOTE: This article is simply for informational purposes and not legal advice. Do not rely on it to make legal decisions about your case. It’s merely to flag issues that you should be aware of when talking with your attorney.
- Medicare (Medicaid): This federal insurance policy typically maintains a “Super-Lien.” Under federal law, if you have a Medicare policy that paid your bills, you should expect them to seek reimbursement. What’s more, if you fail to pay, Medicare will seek legal recourse against you and impose hefty fines for non-payment.
- Federal Health Insurance Policies: Like Medicare, most health insurance Plans through federal employment will have the right to be reimbursed. Such Plans are entitled to reimbursement under the Federal Employee Health Benefits Act (FEHBA). So, if you’re employed by the federal government, or you have insurance through a federal employee (such as a spouse or parent), you need to be aware that reimbursement will likely affect your case.
- Worker’s Compensation: If your worker’s compensation plan paid your bill, the Plain will seek reimbursement. You will need to discuss with an attorney the complexities of the cases.
- Fully Self-Funded, ERISA Policies: While Virginia’s Anti-Subrogation prevents reimbursement, some Virginia polices are written in federal law, which preempts Virginia Law. Indeed, the Employee Retirement Income Security Act (ERISA) provides that fully self-funded ERISA health insurance policies that are EIRSA compliant are entitled to health insurance reimbursement. And while other polices may give you a pro-rata discount for attorneys’ fees, if spelled out in the self-funded ERISA policy, under McCutcheon v. US Airways, you are not entitled to a discount to their health insurance reimbursement for your attorneys’ fees.
Not sure what kind of health insurance policy you have, or whether it’s a self-funded ERISA Policy?
You need to talk to your attorney. Indeed, for some policies above, an attorney has an affirmative obligation to reach out to the health insurer to determine the reimbursement amount. This is particularly true for Medicare reimbursement.
What happens if I don’t reimburse my Plan, and they are entitled to money?
Long story short, you don’t want to find yourself asking this question. As discussed above, Medicare’s super lien has harsh consequences for non-payment. These include being sued for the money and incurring substantial late fees.
Other consequences can include being kicked off your health insurance plan and having no future coverage. So, you need to talk to an attorney about your obligations before settling a matter, particularly if you feel that you’re not required to reimburse your health insurer.
Still have questions?
Make sure to check out our Personal Injury & Criminal Defense Practice Pages where we’ve answered many other questions you likely have. James Abrenio is a Fairfax-Based Personal Injury & Criminal Defense attorney who practices throughout Northern Virginia. You can learn more about James Abrenio, some of our Prior Results, and Read Our Reviews. Make sure to contact us at Ph. 703-570-4180 for your Free Consultation.