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Health Insurance Reimbursement in Personal Injury Cases

Updated: Aug 17, 2020

Health insurance companies such as United Healthcare, Blue Cross Blue Shield, or Aetna may have paid your medical bills after you are injured in a car or truck accident. If you recover any money from the person who negligiently injured you, these health insurance companies may be entitled to reimbursement for any payments they made to health care providers who treated your injuries, including hospitals and chiropractors. If you’re thinking that you’ll just ignore their requests to be reimbursed, the consequences can be severe, including cancellation of your health insurance and even being personally sued for the amounts entitled to reimbursement. Having a competent personal injury lawyer work with your health insurance company is the best way to avoid this hassle.

How Do I Know If My Health Insurance Company Is Required to Be Reimbursed?

You should contact your attorney to review your plan policy. If you’d like to find out yourself, call the number on the back of your health insurance card and ask the representative to speak with a member of their legal department.

Is My Health Insurance Carrier Truly Entitled to Reimbursement?

If you receive insurance coverage through your employer, your plan will likely require reimbursement for medical expenses paid from any settlement you recover. You will need to ask your attorney to review the actual language of the policy to see if the plan requires reimbursement of any medical expenses paid in your behalf. If you have health insurance through your employer, then the plan will most likely be considered an ERISA plan. ERISA plans are subject to Federal law, and plans that fall under this category are typically entitled to reimbursement, though the plan language still has to specifically provide that the insurance company has this right. Your agreement with your health insurance carrier is, afterall, a contract.

Plans that are not ERISA (typically those purchased by self-employed individuals or for those of you who decided to purchase insurance outside your employer) are governed by Georgia state law, which is generally more favorable to the policy holder than ERISA plans. Georgia follows the “made whole” doctrine. This doctrine provides that Georgia does not permit subrogation by insurance companies that have made health insurance payments from an injured person’s personal injury settlement unless that person is “made whole.” See OCGA 33-24-56.1

To be “made whole”, you have been fully compensated for all your damages, including medical bills, lost wages, and pain and suffering.  See OCGA 33-24-56.1. Fortunately for non-ERISA Georgia policyholders, a jury must make a special verdict in your favor that specifically lists damages for each category for you to be considered “made whole.” If your case settles and does not go to trial, you can’t be “made whole,” and the health insurance company can’t come after your settlement money.  Because only a small percentage of cases make it to trial, most policyholders in Georgia won’t have to worry about reimbursing their health insurance company.

Remember to consult with an experienced personal injury attorney if you’ve been injured in the Cartersville area. While not all plans require you to reimburse your health insurance carrier, if you receive insurance through your employer, you should expect them to put a lien on your personal property settlement. Fortunately, your attorney will treat them like any other creditor and work with them to reduce the amount owed.

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