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Body parts in MSA and settlement docs don't match
#21
(01-31-2018, 02:33 AM)Shadow Wrote: I hear of people saying they can get coverage for a comp injury on a private policy ..I find it interesting people say that. When I look at the Evidences of Coverage for say a Blue Cross policy it contains a subrogation clause that precludes third party claims and the insured must notify the carrier that some one else holds iability for the medical bills within 60 days so the carrier can lien other claims. Such as a comp carrier. I suspect ( but i dont know for a fact ) that people are not being honest when having another insurance company pay medical bill that arose from a work injury. I was taught that no private insurance company is going to accepts liability for medicals that another hold liability for. I have just never seen it ..maybe I'm wrong. Typing is hard for me due to disability. I feel your frustration. Call a private medical insurer and ask .. I think the answer is going to be No ! or they will and maintain subrogation rights.

Shadow,
A friend gave me some valuable information on your concerns. The laws on subrogation will vary from state to state.

I don't know what state you're in, but in CA there is a law called Knox-Keene. Look it up and go to Article 3.15 on Preexisting Condition Provisions. Under 1357.51, you will see that group policies in CA are not allowed to impose any preexisting condition or any waivered conditions.

With Individual coverage, the rules depend on whether the plan was in existence at the time of the ACA act becoming law (ie grandfathered), or if it's a new policy established after ACA became law (ie non-grandfathered). However, with either type, the maximum amount of time a condition could be excluded would be 12 months.

I called the CA Dept of Ins to make sure I was understanding Knox-Keene correctly.

If you're in CA, I suggest you take a look at this Knox-Keene law and then call the CA Dept of Insurance to answer any more specific questions you might have.

If you are in CA and your wife's policy states there is subrogation, I'm thinking there may be new riders or a new version of the policy to reflect the newer CA laws. If it's a group policy, then perhaps she should check with her HR dept for an updated plan description.

If you are in another state, you should call your state's Dept of Insurance regarding laws that are specific to your state.

If the work comp carrier is offering you an opportunity to get out of the work comp system and the offer is reasonable, I'd hate for you to stay in work comp if you don't need to. As I understand, generally the longer a case goes on, the harder the IC fights to prevent you from getting real care.

Good luck to you!
 
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#22
If you C&R your work comp case and have private insurance you can use it as you no longer have a WC claim.

There are federal laws protecting those with pre existing conditions. Private insurance cannot exclude a patient for treatment because they have a closed work comp claim they C&R'd.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#23
Seems a bit unethical to accept settlement dollars for future medical and then ask your health insurer pick up the tab.
Can you provide a citation?
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#24
(02-01-2018, 11:40 PM)California_Help Wrote: If you C&R your work comp case and have private insurance you can use it as you no longer have a WC claim.

There are federal laws protecting those with pre existing conditions. Private insurance cannot exclude a patient for treatment because they have a closed work comp claim they C&R'd.

When you C and R a claim that means you have received money for the medical portion of that claim ..meaning now you the claimant are responsible for the medical bills , not a private insurer. 

Denied treatment can be covered but the private insurer reserves subrogation rights. They must be notified within 60 days that the bills they are paying are the responsibility of another Insurance Company or... someone who sold their medical is now the responsible party. Misrepresenting that facts ( causation and workers comp )  to a private insurer has severe consequences.

Pre- existing conditions are absolutely covered such as diabetes or Autism. You are 100% correct.

Not pre - existing workers comp claims that result in a need for future medical care awarded by a court.

I have Federal Medicare . They will not pay 1 cent for a " known " workers comp claim unless a MSA is completed. Anyone cost shifting to them goes in to the lake of fire Smile

For example a Car Accident . The private insurance picks up the bills , liens the case and subrogates.

I say to people ..have you read the comprehensive "evidence of coverage"  and policy declarations on your private health insurance plan ?  Do you know your policy . It's a contractual agreement.

In my humble opinion. I think  folks are BS ing their providers and receiving coverage and concealing the fact the treatment being sought arose out of the course of employment ,and the injury is accepted , or has been accepted. That a workers comp insurance company holds liability , or at one time did hold liability but the claimant sold the medical.

I am looking at an Anthem Blue Cross book right now . A guide to understanding your benefits . Know as the "contract". Under third party claims  page 155 .  It states that the insured will cooperate and notify the insurer of and third party claims within 60 days, including workers compensation. Its a lot of legal jargon . Talks about furnishing papers , lien rights, cooperating with investigations. The contract goes on to talking about settlements, judgement and subrogation. Collection from private estates .Says you the policy holder agrees not to prejudice our rights or interest under this agreement. failure is a breech of contract with civil liability etc ..

So yes a private insurer will cover pre existing conditions , pre existing injuries. They can also do a full investigation to make sure they are not be defrauded and assign liability correctly. They cannot be deceived or denied this. In some cases they will sue the policy holder for withholding material facts. For example the Compromise and Release.

When I hear people say you can shift your workers comp in to private insurance. I have my doubts and wonder how is this person doing this ? Is it that the care or case is denied ? Is it that they have exhausted the IMR process ? Is it that they C and R'd and are lying about causation and not mentioning the settlement. What is it that the private insurer is covering and why ? Does the private insurer know all the facts? Does the treating doctor know all the facts. Sometimes treating doctors like cost shifting too . It's easier to get paid.

An insurance company is not going to " knowingly " accept liability that another insurance company holds liability for or held liability for.

Do you know your evidence of coverage for your private health insurance policy ? Do you know what your responsibilities are under the "contract " as a policy holder?

Its just not that simple.

With respect,

Shadow
 
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#25
(02-01-2018, 11:56 PM)1171 Wrote: Seems a bit unethical to accept settlement dollars for future medical and then ask your health insurer pick up the tab.
Can you provide a citation
I would like to see a citation too . This has been a hot topic since the ACA.
 
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#26
(02-01-2018, 06:22 PM)Seeking Help Wrote:
(01-31-2018, 02:33 AM)Shadow Wrote: I hear of people saying they can get coverage for a comp injury on a private policy ..I find it interesting people say that. When I look at the Evidences of Coverage for say a Blue Cross policy it contains a subrogation clause that precludes third party claims and the insured must notify the carrier that some one else holds iability for the medical bills within 60 days so the carrier can lien other claims. Such as a comp carrier. I suspect ( but i dont know for a fact ) that people are not being honest when having another insurance company pay medical bill that arose from a work injury. I was taught that no private insurance company is going to accepts liability for medicals that another hold liability for. I have just never seen it ..maybe I'm wrong. Typing is hard for me due to disability. I feel your frustration. Call a private medical insurer and ask .. I think the answer is going to be No ! or they will and maintain subrogation rights.

Shadow,
A friend gave me some valuable information on your concerns.   The laws on subrogation will vary from state to state.  

I don't know what state you're in, but in CA there is a law called Knox-Keene.   Look it up and go to Article 3.15 on Preexisting Condition Provisions.  Under 1357.51, you will see that group policies in CA are not allowed to impose any preexisting condition or any waivered conditions.  

With Individual coverage, the rules depend on whether the plan was in existence at the time of the ACA act becoming law (ie grandfathered), or if it's a new policy established after ACA became law (ie non-grandfathered).   However, with either type, the maximum amount of time a condition could be excluded would be 12 months.

I called the CA Dept of Ins to make sure I was understanding Knox-Keene correctly.

If you're in CA, I suggest you take a look at this Knox-Keene law and then call the CA Dept of Insurance to answer any more specific questions you might have.

If you are in CA and your wife's policy states there is subrogation, I'm thinking there may be new riders or a new version of the policy to reflect the newer CA laws.   If it's a group policy, then perhaps she should check with her HR dept for an updated plan description.

If you are in another state, you should call your state's Dept of Insurance regarding laws that are specific to your state.

If the work comp carrier is offering you an opportunity to get out of the work comp system and the offer is reasonable, I'd hate for you to stay in work comp if you don't need to.  As I understand, generally the longer a case goes on, the harder the IC fights to prevent you from getting real care.

Good luck to you!

See my post below ..sure they''ll cover it and turn around and seek reimbursement from the insured . As the insured holds liability when they took the C and R for the medical. The only C and R with medical is MSA. Can't take the cash ,stash it , turn around and expect another carrier to pay for the work injuries.
 
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#27
My family member has Blue Shield this year . Here is one of the exclusions . Taken right off the web page under exclusions, 2018 Policy just issued Jan 1st.

For those people that think you can C and R a claim and shift it to a private health insurer .

Blue Shield can ask you the claimant for reimbursement out of your C and R because you have the money for medical in your case.

Pre -existing conditions are covered .Not pre- existing claims .

Here is from the list of exclusions:

Illness/Injury Connected to Employment – This exclusion applies to:

(a) any injury arising out of, or in the course of, any employment for salary, wage or profit, or
(b) any disease covered, with respect to such employment, by any Workers’ Compensation Law, occupational disease law or similar legislation.

However, if Blue Shield provides payment for such services, it shall be entitled to establish a lien upon such other benefits up to the reasonable cash value of benefits provided by Blue Shield for the treatment of the injury or disease as reflected by the provider’s usual billed charges.

Respecfully

Shadow
 
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#28
I suspect there is similar language in most other standard health coverages. Just like CMS, they want to limit the opportunity for a double recovery.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#29
(02-02-2018, 05:21 AM)Shadow Wrote: My family member has Blue Shield this year . Here is one of the exclusions . Taken right off the web page under exclusions, 2018 Policy just issued Jan 1st.

For those people that think you can C and R a claim and shift it to a private health insurer .

Blue Shield can ask you the claimant for reimbursement out of your C and R because you have the money for medical in your case.

Pre -existing conditions are covered .Not pre- existing claims .

Here is from the list of exclusions:

Illness/Injury Connected to Employment – This exclusion applies to:

(a) any injury arising out of, or in the course of, any employment for salary, wage or profit, or
(b) any disease covered, with respect to such employment, by any Workers’ Compensation Law, occupational disease law or similar legislation.

However, if Blue Shield provides payment for such services, it shall be entitled to establish a lien upon such other benefits up to the reasonable cash value of benefits provided by Blue Shield for the treatment of the injury or disease as reflected by the provider’s usual billed charges.

Respecfully

Shadow

This is all very interesting, but is leaving me rather confused. Shadow, thank you for posting the above. I'm not sure how to put all this information together at this point.

I wonder why the person from the Department of Insurance didn't mention to me that a new insurer could legitimately ask for reimbursement for treatment when there had been a prior work injury. That's a rather important bit of information to leave out. I specifically asked about a person with a prior work injury later going back to work at a new job with group coverage. I indicated there might still be some amount of medical care needed for the former injury.

In 1357.51, the Knox-Keene Act law says:
(a) A health benefit plan for group coverage shall not impose any preexisting condition provision or waivered condition provision upon any enrollee.

Rules for a non-grandfathered individual plan say the same thing.

To me, the above wording seems to say it is ok to use the new insurance, but Shadow's wording from the policy is very clear too.

The Knox-Keene act/law also says, "A "waivered condition provision" means a contract provision that excludes coverage for charges or expenses incurred during a specified period of time for one or more specific, identified, medical conditions."

Could I be misunderstanding the above definition of "waivered condition provisions" (which aren't allowed in the policies)? Are they different from exclusions such as a work injury?

Thanks for helping me understand this. I definitely don't want to spread misinformation.
 
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#30
(02-02-2018, 02:34 PM)Seeking Help Wrote:
(02-02-2018, 05:21 AM)Shadow Wrote: My family member has Blue Shield this year . Here is one of the exclusions . Taken right off the web page under exclusions,  2018 Policy just issued Jan 1st.

For those people that think you can C and R a claim and shift it to a private health insurer .

Blue Shield can ask you the claimant for reimbursement out of your C and R because you have the money for medical in your case.

Pre -existing conditions are covered .Not pre- existing claims .

Here is from the list of exclusions:

Illness/Injury Connected to Employment – This exclusion applies to:

(a) any injury arising out of, or in the course of, any employment for salary, wage or profit, or
(b) any disease covered, with respect to such employment, by any Workers’ Compensation Law, occupational disease law or similar legislation.

However, if Blue Shield provides payment for such services, it shall be entitled to establish a lien upon such other benefits up to the reasonable cash value of benefits provided by Blue Shield for the treatment of the injury or disease as reflected by the provider’s usual billed charges.

Respecfully

Shadow

This is all very interesting, but is leaving me rather confused.   Shadow, thank you for posting the above.  I'm not sure how to put all this information together at this point.

I wonder why the person from the Department of Insurance didn't mention to me that a new insurer could legitimately ask for reimbursement for treatment when there had been a prior work injury.  That's a rather important bit of information to leave out.   I specifically asked about a person with  a prior work injury later going back to work at a new job with group coverage.  I indicated there might still be some amount of medical care needed for the former injury.

In 1357.51, the Knox-Keene Act law says:
(a) A health benefit plan for group coverage shall not impose any preexisting condition provision or waivered condition provision upon any enrollee.

Rules for a non-grandfathered individual plan say the same thing.

To me, the above wording seems to say it is ok to use the new insurance, but Shadow's wording from the policy is very clear too.

The Knox-Keene act/law also says, "A "waivered condition provision"  means a contract provision that excludes coverage for charges or expenses incurred during a specified period of time for one or more specific, identified, medical conditions."

Could I be misunderstanding the above definition of "waivered condition provisions" (which aren't allowed in the policies)?     Are they different from exclusions such as a work injury?

Thanks for helping me understand this.  I definitely don't want to spread misinformation.


I always suggest the policy holder look over their Health Insurance Contract under Evidence of Coverages and The Insureds rights and responsibilities .. the devils is in the details. Private insurers just aren't going to eat medical bills that are the responsibility of someone else. Injured worker here since 1999. I have researched this for years especially since the ACA came in. My own attorney tried to tell me its covered under private insurance. It was Malarkey. They do cover pre existing conditions , not pre existing claims  . As stated before I think a lot of people are BS ing their way through on this. I wouldn't want to be the target of a private insurers investigation . Could wind up being a real bad day for someone .
 
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