Your Injury Claim and Your Health Insurance
I could write almost endlessly about the interactions between your North Carolina injury claim and your health insurance, but as I was composing this post I realized that, distilled to its essence, what this really boils down to is in-flow and out-flow.
In-flow
You get your health insurance by paying for it, one way or another. The deal is that when you need it, they pay for stuff for you. For purposes of this article, I’m thinking of that as “in-flow” because it’s money/benefits coming into your situation from an outside source. The way I look at it is that you have (if you’re lucky) several sources of funds that are putting money into your claim bucket: a liability carrier, perhaps your auto policy in the form of med pay coverage, and hopefully health insurance. How does that impact your injury claim? YOUR HEALTH PLAN SHOULD PAY FOR YOUR HEALTH CARE. I can’t repeat this often or loudly enough, so I’ll do it once more. YOUR HEALTH PLAN SHOULD PAY FOR YOUR HEALTH CARE. Yes, if you’re injured in North Carolina, YOU are responsible for your health care (NOT the at-fault party), which means your health plan is now responsible for your health care. We do NOT wait around for the liability carrier to pay for anything (they won’t). We do not assume anyone else is responsible for our care! We are NOT a PIP state and we do not do Coordination of Benefits when it comes to injury claims. If you seek health care, for whatever reason, your health plan should be on the hook. Now, there are some rare times that you might not want to use it (like with super-frequent care that you might get from a chiropractor) because of the frequency/amount of co-pays, but when in doubt, use your health insurance!
Out-flow
But do benefits ever go the other way? Do we ever have to pay the health plan back? YES! But not always! North Carolina has an anti-subrogation rule, meaning that the average state-specific health plan does NOT have a right of reimbursement in third party claims, meaning we generally do not have to pay your health plan back. However, there are exceptions to every rule. And there are several here. The most common is Medicare. You have to pay Medicare back from your settlement, but I’ve written about that elsewhere. Medicaid is pretty much the same, though with a different, more cumbersome and unreliable process (you guys who work there aren’t great…sorry, but it’s true). The State Health Plan has a statutory “super lien” which means they get paid back before, over, and above anyone (after attorneys) so you really have to watch them. Finally, even if you live in NC you might work for a large employer that’s set up their health plan through a Federal law (overrides NC law) that allows for reimbursement in third party settings. That law is referred to as ERISA and it gives me no end of grief. You probably won’t know if you have this sort of plan without asking, but the problem is that the people who answer phones at these places often don’t understand the question you’re asking, so it can be really difficult to learn your responsibilities in this situation. If no one there can seem to tell you, then you’ll want to get the Summary Plan Description of your plan and look at it. That will tell you what you need to know, but you may have to read 80 pages of nonsense to get there.
Look, injury claims get way more complicated than any of us would like, so get some help. Call an experienced attorney to get the guidance you need so you don’t inadvertently make things worse than they already are. Call me at 919-929-2992.