Injured Workers & Private Health Insurance

Injured workers have contractual obligations to their private health insurance carrier. Huh? Interpretation please.
When you get hurt at work and get medical treatment through your private health insurance (i.e., PEHP, SelectHealth, Blue Cross Blue Shield, etc.), you might receive a letter in the mail asking you to provide workers comp claim information to your private health insurance. Why? When you sign up for private health insurance, you enter a “master agreement” which spells out what the health insurer will do (i.e., pay for doctors and hospital visits) and what you will do (i.e., notify them if the medical treatment was for an industrial, on-the-job injury). By contract, the health insurance company will need to be reimbursed by the workers compensation carrier (i.e., WCF, Travelers, S&C, etc.) because the workers comp carrier should have paid for your medical treatment. This contractual right to reimbursement is called subrogation.
Here’s how this “subrogation” thing often plays out: You get hurt at work and the workers comp carrier (“WC” for short) denies your claim because WC says you had a pre-existing condition. So, you follow SelectHealth’s rule and provide a copy of the WC denial to SelectHealth. (See their website here.) Then, SelectHealth pays for your medical care. Later on, you talk with an experienced workers comp attorney and discover that your workers comp claim is actually valid despite your pre-existing condition, so your attorney helps you file an application for hearing. If you go through the full litigation process and win, the Labor Commission judge orders WC to pay for your medical care, which means WC needs to reimburse SelectHealth. Likewise, if you and WC settle rather than continue litigation, then your attorney will likely negotiate a reduced reimbursement amount with SelectHealth as part of the settlement process. You and your attorney ensure some of the settlement money is used to pay off SelectHealth’s right to reimbursement.
Be sure to tell your workers comp lawyer whether you have private health insurance. It is super important that injured workers and their attorneys talk about all private health insurers who have paid for any of the injured worker’s care over the past months and years.
Lastly, the above info also applies to government health insurers. Medicaid and Medicare also have subrogation rights and must be notified when they pay for treatment that was due to an industrial, on-the-job injury. If you have questions, call Tim Daniels Law Services at (435) 592-1235.

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