There are many policies that will
provide for 100% reimbursement, up to a certain dollar limit, for an accidental injury. If you fall in the backyard and injure your leg
and require an orthopedic visit and perhaps physical therapy, your insurance company will
want to know how you were injured. They will
send you a questionnaire before they pay any claims.
You simply state the facts. You
tell them you fell in the backyard and injured your leg.
If your policy provides 100 % coverage for accidents up to a certain point,
the insurance company now has the information they need to process the claim at 100 %
reimbursement. Or, perhaps it might be 80
percent reimbursement or 70 percent reimbursement, whatever the case may be. An insurance company will always want to know how
the accident happened. They want to make sure
that they are the responsible party for paying the claim.
If there is a potential liability suit because you got hurt on someone
else’s property which was not properly maintained, the insurance company will want
the liability insurance carrier to pay the claim. Likewise,
if you get injured at work, on the job, this is a workmen’s compensation claim, not a
claim for your private health insurance.
If you work for a company in New Jersey
with fewer than 50 employees, or if you purchased health insurance on you own, there is a
$50 penalty (or co-payment) that you must pay if you go to the emergency room and are not
admitted to the hospital within 24 hours. This
is a State mandate. When you go to the
emergency room, you will get a bill from the hospital for the use of the emergency room
and you will get a bill from the emergency room physicians who treated you. The $50 penalty will be in addition to any portion
of your deductible that has not yet been met, if your insurance requires that the
deductible be applied toward emergency room visits. The
emergency room is just about the most expensive place to go for medical treatment. It was never intended to take the place of your
doctor’s office. If you are just sick,
you should be calling your physician and making an appointment to see your doctor in the
office. That is the most cost effective way
of receiving health care. If you get hurt, or
have a life-threatening emergency, get to the emergency room as quickly as you can. The emergency room is intended for emergencies. Most insurance plans require that you call the 800
number within 48 hours to let them know that you have been treated in the emergency room. Be sure to study your health insurance plan to see
what the rules are if you require emergency room treatment.
Automobile accidents, of course, are
covered by your automobile insurance. Some
people may have elected to have their health insurance carrier be the primary insurer in
the event of an automobile accident. You
should check with your auto insurance carrier to find out how you designed your auto
insurance coverage. Just who is primary if
you have an auto accident? If you are
eligible for Medicare and you have the traditional Medicare plan, your auto insurance is
primary and whatever is not covered by your automobile insurance then can be forwarded to
Medicare.
If you are on the traditional Medicare
program and you injure yourself in the backyard or some other place, you can make an
appointment with your physician’s office or go to the emergency room, depending on
the severity of your injury. Medicare handles
accidental injuries the same as any other illness. If
your health insurance coverage is through an HMO, make sure you understand exactly how
your HMO wants you to handle accidental injuries. Any
HMO, as well as any other insurance company, will want you to get to the emergency room as
quickly as possible if you are dealing with a life-threatening situation. Otherwise, you should go to your primary care
physician, or get the necessary referral to see whatever specialist you might need to take
care of your injury.
This column is not intended to give
medical advice. We do not tell people when
they should or should not go to the emergency room. Only
you are the best judge of that. The intent of
this article is to let you know how your insurance will handle certain medical expenses
related to an injury. We want to ensure that
you maximize your health insurance benefits.
Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, or visit our contact page.
All content copyright © 2002 Medical Insurance Claims, Inc. unless noted otherwise. All rights reserved.