Author Topic: Persl Injury Settlement Insufficient-> Denied Untimely Filing Health Insr Claim  (Read 2243 times)

PTPatient

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I was injured an a rather bad vehicle accident and was promised by the adjuster for the at-fault party that the policy limit was large.  After two years and around eighty visits to physical therapy I find that the policy limit was actually the minimum allowed by law and came nowhere close to covering all of my medical bills.  This inquiry is specific to my physical therapy visits.  The PT facility originally agreed to bill the auto policy of the at-fault party via a lien, but now that the policy coverage was inadequate to cover all of the PT visits the PT facility agreed to attempt to bill my healthcare insurance.  As expected my healthcare insurance denied all eighty visits because they were not filled within 90 days.  These visits range from almost two years old to about six months old.  I have no interest in informing the health care company about my small settlement.

My question simply is do I have any feasible justification that I can personally argue in an appeal letter to the healthcare company to maximize my changes that they will approve my appeal and process all visits under my healthcare? 

Michele

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You can certainly appeal the denials by advising them of the reason for the delay in filing.  However, I do believe that you will have no choice but to inform them of any settlement information. 

I would contact your health care company to ask them for the process to file an appeal.  It may be able to be done by phone, or you may need to write a letter and include information showing that the automobile policy coverage was maxed which caused the denial of the charges.

Good luck.
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PMRNC

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The PT facility originally agreed to bill the auto policy of the at-fault party via a lien, but now that the policy coverage was inadequate to cover all of the PT visits the PT facility agreed to attempt to bill my healthcare insurance.  As expected my healthcare insurance denied all eighty visits because they were not filled within 90 days.  These visits range from almost two years old to about six months old.  I have no interest in informing the health care company about my small settlement
.

Carriers have what is called ROR (Rights of Recovery) which cover them in the event of a lawsuit that pays suit for charges such as this (PI, auto, etc).  THE magic question is this:  WHO was legally responsible to pay these charges? WOULD the carrier have paid them IF they were timely filed? The next question is this.. did you pay the PT?

IMO I would first see if you have an appeal. If the carrier was never responsible for the charges to begin with you probably won't get them paid, technically this is your problem and the PT has a right to bill you and then you can decide actions to recoup.  If you obtained an attorney, it would be wise to consult with them first.
Linda Walker
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Michele

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Linda,

Out of curiosity, doesn't the fact that they received a small settlement affect things as well?

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PMRNC

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Out of curiosity, doesn't the fact that they received a small settlement affect things as well?

Yes but it depends on the actual settlement. When carriers get a WC, PI or auto injury it's standard practice to send the patient a ROR (Right of recovery) statement. Some policies it's built in. That means they will pay claims but that the carrier has a right to recoup losses when a settlement is in place.. but it legally depends on the actual settlement, who paid the claims, etc. That's why I recommended they talk to an attorney. 
Linda Walker
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Michele

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Thanks.  I need to know "how" things work.   :D
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PMRNC

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For every carrier I worked with they trained us to ask this question whenever dealing with any WC, PI or auto injury "WHO has responsibility" Insurance carriers are in the business of "risk management" If a person is injured and receives a settlement from that injury, the carrier has a right to recoup any monies paid out in conjunction with that medical care. That's why I said a lawyer should be consulted because we don't know the terms of the settlement. The responsible party in the settlement may have only had to pay charges in "excess" of or for "pain and suffering". etc.  If there was a settlement I can only ASSUME their was legal counsel that signed off on the settlement. In any event the PT really doesn't have to do anything more than what they did, so the legal issue of responsibility is between the patient, carrier and attorney. PT is still owed that money from someone.
Linda Walker
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shanbull

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I'm sorry you have to deal with this stress, at our clinic we actually bill the health carrier right away when the auto policy denies a claim so that the patient doesn't have to worry about it. If we don't get any payment from either source we work with the patient's legal team to settle the bill with the at-fault party. It doesn't take that much extra work and it frankly makes me angry to see other clinics not doing this. Like you don't already have enough on your plate!

Even if there has already been a settlement for some portion of the bills, if this PT treatment was not included you still have rights to settle again. If you do not already have legal representation, call to get a free consultation with an attorney who specializes in injury law who will explain your options, and make sure you go with someone who only charges a fee if you win your case, with the other party billed for legal expenses and a settlement with any remaining balance on your treatment costs written off.