Payment of Benefits Pedestrian hit by a car

[Guest erisa15]

A friend's daughter was walking and was hit by a car and sustained injuries as a result. The health insurance company is now telling her that it will not pay any of the related medical expenses for her daughter. In order to get the medical expenses paid she has been told that she must go after the driver of the car and/or his automobile insurance for payment. I have not seen the plan yet but this just doesn't seem quite right. What ifit was a hit and run? Any thoughts/comments/suggestions as always are welcome. Thanks.

[Guest AJK0020]

I think this would vary by plan and state. The plans we offer do exclude payment for injuries covered by manditory no-fault automobile insurance. As far as the hit and run issue, I hope I never have to find out!!

[david rigby]

This would be a surprising result. The employee will probably want the insurance company to document its statement, including demonstrating where such provision is included in the plan/contract.

There is probably also an appeal procedure.

[oriecat]

My insurance contract has a two page section on Third Party Liability (Subrogation). There should be something in her plan about that as well, I would think.

[GBurns]

If your friend has a car, their car insurance should be the stop for medical coverage. Most car insurance policies cover the owner and listed members of the household whether in the car, on foot or otherwise. The payments is triggered by an "automobile accident"?

This automobile insurance coverage would provide the needed medical treatment (up to coverage limits) and the insurance company would be the ones that your friend could get to start pursuit of the other insurance company etc.

Please remind them that they must make a report to the Police and to their insurance company ASAP.

[mbozek]

You need to check the state law on liability for automobile related accidents. In some states the auto policy must provide primary coverge for any auto related injury for a covered dependent (e.g. uninured moterist coverage). The parent must call his/her auto carrier to find out if the injury is covered under the auto policy. The Health ins carrier should be liable for all med expenses in excess of the auto policy coverage. In NJ the auto policy is primary for all medical expenses arising from an auto accident unless the policy holder opts out to have the health ins. carrier made primary.

[mal]

This situation may have arisen as a result of the Supreme Court's

decision in "Knudson." Our self-funded HW plans are struggling

to provide benefits to members injured in accidents while

simultaneously protecting our subrogation rights. Due to the

Knudson ruling, many plans have rewritten their plan documents

to prohibit payments until all issues of liability are settled.

We used to pay benefits when a participant signed the reimbursement

agreement, but due to Knudson, we have few options to

enforce such agreements. I hope this issue is resolved soon

as many participants find themselves in this situation.

[Guest rfh3]

If the plan is insured, the state law remedies noted above are a good place to begin, including contacting the state insurance department, with a cc to the claims administrator. If the plan is self-funded, state law remedies will not apply, but most claims administrators are still licensed in most states, so a note to the insurance department won't hurt. But the real point here is that, regardless of the plan's subrogation/reimbursement wording, no one really knows who is actually legally at fault and whether any resources are available in any accident. Further, most plan language is inadequate to justify pending claims in these situations. A claim for benefits should be made, and any denial appealed - ideally, with the assistance of an attorney.

[GBurns]

A note or complaint to the Insurance Dept against whom?

What would the complaint be aboout?

Subrogation/reimbursement wording of which coverage?

Legally at fault is not an issue at this time, there is coverage under auto insurance and under health plan. The question is, Which one and Why?

[Guest rfh3]

The subrogation/reimbursement wording that must authorize the denial of claim is typically not going to be sufficient to deny the claim in the fact situation presented here. The automobile liability carrier will never agree to pay a dime without a release from the pedestrian. In fact, we could discover that the auto carrier denies responsibility for their driver (imagine that) if, for example, the pedestrian is claimed to have been outside a crosswalk or to have negligently stepped in the way of traffic, or was walking in the road at dusk or whatever. Until such time as the carrier accepts responsibility, and that could take quite a while, _there is no other coverage_ and the plan language will require payment of this participant's claim for benefits. If not, the complaint to the DOL/insurance department would be against the employer, as plan administrator, and the TPA (assuming as self-funded plan) for failure to pay benefits per the plan document. Very simple, really. The best way to solve these problems is through an explanation of the law by the pedetrian's attorney to the plan administrator.