Should Health Insurance Pay Your Bills?

Many of our clients tell us that they don’t want their health insurance company to have to pay their medical bills when someone else is responsible. They’re often worried about their rates going up, or that an insurance company won’t pay the bill because it’s not their responsibility. So should health insurance pay your bills?

It’s important to remember that you’re the one that was injured, because of another person’s fault.  Down the road that person is going to pay. But right now, your main goal is to not have to pay money out of your own pocket. Also, it is very unlikely that the health insurance company will not be reimbursed in some way later when you make a recovery.

Health insurance companies are in the business of taking on this loss, whereas our clients or potential client is not. Let the insurance companies do it. Health insurance plans typically have a clause that says if you are harmed, and you seek medical care because of that harm, and someone else caused that harm, that they get their money back that they’ve paid out. The statutory scheme upon which they can claim their money back is either the federal ERISA statute or Florida Statutes.

How do Federal ERISA Statute and Florida Statutes Compare?

Your health insurance plan decides whether the Federal ERISA or Florida Statutes applies to you.

Florida Statutes

Employment plans through a government entity, such as the school board, or the sheriff’s department, then your plan is governed by Florida Statutes. Or if you purchased your plan on the exchange or through your own agent on your own, then that would be governed by the Florida Statutes.

Florida ERISA Statutes

If you work for a large company that is self-insured, such as L3 Harris, or Grumman, then your plan is most likely governed by the Federal ERISA statutes.

Health Insurance Plans and the difference between Federal ERISA Statutes or Florida Statutes?

Florida Statutes

It is typically in your best interest that your plan falls under the Florida Statutes. Under the Florida Statutes, that plan is only entitled to receive back their pro-rata share of the amount that they paid out that you recovered. In other words, if for some reason something goes wrong with your case, and you only recover a small portion, they are only going to be able to receive back or be reimbursed on that value.

For example, you get hurt because of someone else’s negligence, and you go to a doctor and pay $100. Then you get the health insurance company to pay that doctor. At the end of the case, the insurance company will want their $100 back.

Overall of your case is worth $200,000, and you receive $100,000, in return, because that is all the insurance covers, then that $100 paid by the insurance company is going to be reimbursed $50. It will actually be less that than because you’ve paid attorney fees and costs that they have to pick up their pro-rata share.

As you can see, a lawyer’s job is not always done at settlement. Oftentimes, the real work and the hard part of the case is maximizing that recovery by dealing with these health insurance carriers who have paid out on some of your medical bills.

Federal ERISA Statutes

Unlike the federal statutes, the Federal ERISA statutes (if they have the language in their plan, and they all typically do) are entitled to every penny that they’ve paid out. Even if you’ve only recovered a fraction of the value of the case. It’s not really fair.

Luckily, we are normally able to deal with these insurance companies, not always, and have them reduce the amount that they will accept. In other words, they recognize that you’ve had to pay an attorney, that you had a pre-existing condition, maybe you had some fault that contributed to the crash, or maybe there was limited liability coverage. They understand that in those situations, you did not recover the

These can be very complex matters. This is why it’s very important to hire a lawyer that can help you navigate this because the case is only over when all these issues are resolved.

Let Us Help You with Complex Insurance Claims

If you are injured in a car wreck, trip, slip, and fall, where someone else is at fault, allow your health insurance company to pay those bills. Let the attorney determine which laws apply and pay them back the appropriate amount.

You benefit when those insurance companies pay those bills, and typically at an adjusted rate or reduced rate because of contracts. And in those situations, they only recover the amount they paid out. If you have any questions, visit us online, or call us on (321) 233-9885.

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