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Workers Comp, BC/BS and Medicare
#16
(03-06-2018, 08:30 PM)California_Help Wrote:
(03-06-2018, 04:12 PM)Shadow Wrote:
(03-06-2018, 03:23 PM)California_Help Wrote:
(03-05-2018, 11:16 PM)Shadow Wrote: https://www.healthcare.gov/coverage/pre-...onditions/

The above has information about pre-existing conditions. Grandfathered policies ended on 2014. Unless you purchase private insurance outside of the enrollment period they should cover pre-existing conditions.

"All Marketplace plans must cover treatment for pre-existing medical conditions.
•No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.
•Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health."


So how does this affect an injured worker that sold the medical.


Is this specific clause that you have posted legally binding on a private insurance companies reimbursement and subrogation rights ?

What you have posted could lead an Injured Worker to believe their work related injury or illness is still covered regardless of releasing future medical.

No one disputes the ACA covers pre existing conditions. How does this relate to to the original question.

The original poster asked if another would accept liability after the medical is sold out for a knee injury.

The answer is no !

Just call the private insurer and explain you have this work injury , sold the medical and now want them to pay for care .. no problem right?

Just let the treater know that you have this work injury and are now billing private insurance , you sold the medical... no problem right ?

Cite the affordable care act if you get a denial for a preexisting condition with an existing or preexisting liability Smile

The ACA 's pre existing condition clause and an insurers right to recovery are two completely different issues.

Injured Workers beware of this misinformation. Sell your medical ..you're in a really bad place if you need medical care. You are not covered.

No one can provide a health insurance policy that accepts liability for a workers comp claimant that sold their medical ... no one ..ever !!

Please post it Smile

There is no "liability" for a closed work comp claim in regards to private insurance. The same goes for people who have injuries that resulted in a civil award.

I do not believe there are links to what you are asking for because it is a non issue as private insurance covers ALL preexisting conditions, unless you purchase private insurance outside of the enrollment period as those policies do not have to abide by rules of ACA or cover preexisting conditions.

The article 1171 posted states people with closed WC claims will be paying for insurance premiums, co-pays and deductibles. They are not getting a free ride.


The private insurance policies are very clear on excluded work injuries. People can spin it all they want .The liability is on the worker now ..they sold out. Civil awards typically don't have an FMC award ..some do and money is placed in a trust. Civil claims typically seek subrogation and reimbursement when the case setlles . An auto accident will run trough the private insurer . I personally had to use all of my MED PAY on my auto first , then private insurance paid and went after the responsible party.

Two things you do not recognize 1- The policy excludes work related injuries. 2 - The ACA does not eliminate a private insures right to reimbursement where there is existing liability for a pre- existing condition.

The article 1171 posted is interesting. So is the video and it's specific language.

Just look at the exclusions in a typical policy ..they go on and on, not just workers comp , acts of war and countless other exclusions.

To lead someone to believe the ACA covers everything is just simply false.

If you go to an honest doctor here in Ca , try to bill private for a sold out wc medical ,they will turn you away

I know people that are cost shifting this way, they are withholding information and making mis- representations to obtain coverage.

Walk in to Kaiser and try to cover your work injury using your private insurance. Smile Especially if Kaiser was in the MPN to begin with.

What I am asking is : Can anyone on the WWW show a private health insurance policy ( in 50 states ) that does not have a workers comp exclusion ..the answer is no.

There is no WC exclusion when your WC claim is closed. If your work comp claim is closed there is no subrogation rights unless you used your private insurance when your work comp claim was open and they have liens then they can attempt to collect from the wc carrier.

I have never had one injured worker from any state after 2014 state their private insurance would not cover their work related injury after they completely closed their claim. Not one. The entire point behind passing legislation that would include all injuries and illnesses was to do away with loop holes that prevented people from getting treated. Also before the ACA many injured workers were able to use their private insurance from their spouse or work after closing their work comp claim. This issue you are writing about is no longer an issue.

I called Kaiser (California) and asked a customer service rep if they covered work related injuries from a prior closed claim and was told they cover all preexisting conditions including those that happened at work. The customer service rep reluctantly talked to me because I did not have a policy with them but gave meilling the info anyway. I also asked if he had come across any members who had problems accessing treatment in this scenario and he replied no. If Kaiser is your carrier I recommend calling them.


Once again you refuse to acknowledge the ACA does not legislate away the reimbursement and workers comp exclusionary provisions of the private insurers contracts.

You are correct on subrogation.

I dont have Kaiser .. I do know a person who was under occupational care for a work injury , sold the medical , went back 2 years later basically for the same injury under a private group policy ..Kaiser attempted authorization for the comp claim they had on file ,got denied of course. So patient was denied care ..sold the medical .Down the road they went, got sent packing . Kaiser basically told the patient to get authorization ( for the work injury ) and they would treat..smart actually. This is why I said Kaiser.

I also know a few people that are treating with private insurance and twisting the facts to get coverage for an excluded work injury. Some doctors are even on board . They also site the ACA but not the exclusions ..how funny !They all forget to report the truth .

I would sure hate to be the one under investigation for it.

Wonder why the person from New York ( knee injury ) doesn't just take out a policy and demand coverage for it under the ACA ?

So in theory I can sell my medical in February ( with fairly extensive future surgical needs) now. Get say 50 grand in March, buy a new truck then turn around take out a private health insurance plan in April. In May bill the private health insurance for the surgery ( I needed due to work injury ) have those procedures and dump the private insurance in June . Cite the ACA to defeat the exclusions in the policy.

Hooray ! Man I'm calling my lawyer .. need that new truck. I mean.. I have been holding on to this usless FMA for nearly 20 years Smile I know once I explain I want to sell my medical, my lawyer will move my file to the top , call the carrier and this could be done super fast . I know the comp carrier wants out for sure. I have been hanging on because of my fairly complex injuries. I didn't know the private insurers would take care of me for life like this !!

So now I decide Ford F 150 or Chevy Silverado.

So back to the original poster : Doesn't matter if she has a 7 year old knee injury and sold the medical .According to the information provided on this message board your client is good to go . If she has coverage now they must pay , if she doesn't take out a plan and they must pay. Your client is covered !!

Thanks to California Help we are all covered and understand the ACA . Those darn pesky work related exclusions and expense reimbursement clauses.

To wguage52 .. I am very sorry this turned in to a debate at your posting expense. Looking at your states WC laws and knowing the typical current policy exclusions, I hope you can extrapolate what the truth actually is ? Perhaps talk to Board Certified Workers Comp Specialist in your area. Maybe an insurance attorney or an insurance company themselves.

Good luck
 
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Messages In This Thread
RE: Workers Comp, BC/BS and Medicare - Shadow - 03-06-2018, 10:15 PM

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