*One of the services we are inquiring about:
Treatment Date: 01/15/2015
Medical Provider: John Doe Medical Center Event Number: 1234567 - Please have this number ready
Dear Valued Member:
Insurance Company partners with Martin Investigators to review medical services provided and/or paid claims that may have been the result of an accident or injury. Martin Investigators , working on behalf of Insurance Company, needs detailed information to determine whether another party is responsible for the medical treatment provided.
Please call Martin Investigators today and have your event number, listed above, along with your Insurance Company identification card ready for reference. Please call regardless or how or where this injury or illness occured.
Your prompt response will be greatly appreciated and will eliminate the need for future contact regarding this information.
Sincerely,
Corporate Reimbursement/Subrogation
Note: Please call Martin Investigators at 555-555-5555 today.*
This was a letter I received in the mail today. What are they really looking for? Are they sniffing around to see if this was a workplace injury?
Most important, what is the best response to give to such an inquiry? Should I be very simplistic and vague, or should I disclose the entire story?
I’ve gotten that letter every time I’ve sought medical treatment for an injury.
They’re looking to see if it could be one of two possibilities that might let them partially off the hook from paying:
If it happened on the job then workman’s compensation is responsible.
If it happened in some location not in your house or in public then some other entity might be responsible. E.g. if it happened in a store then they might sue the store owners to get the money.
I’ve always answered honestly and they’ve never bothered me more. But then, all my injuries occurred either at home or in public.
I collapsed on the tennis court at a tennis club. I’d been feeling poorly for a few days but was soldiering on as I did in those days. Turned out I had pneumonia. I was in the hospital for a couple of days.
I had excellent insurance coverage via my Fortune 50 employer. Nevertheless, for two years I battled the insurance company. They kept insisting that I was not cooperating in establishing the liability of the racket club, the USTA, even one of the other players who happened to be a doctor and called the ambulance.
They kept denying payment and I kept getting bills from the hospital, doctors, the ambulance service and a radiology lab. I finally paid some of the smaller bills (a couple thousand all together) just so that I would only have one remaining delinquency on my credit record. Finally had to get a lawyer to get the $11k hospital bill paid.
So the idea that answering the questionnaire honestly will get you off the hook isn’t very convincing to me.
Frankly, how long they pursue this is a function of the amount in play.
The worst possible course of action would be to lie.
Depending on the injury, “in the home” might work - but a lie (and they can smell lies) would get additional questions - such as “how many forklifts do you have in your home?”.
I had something similar happen when I sought follow-up treatment for ortho issues that stemmed from a bad ankle fracture after a fall several years before. Every time I went to my ortho, whatever he did at the visit, I would get this 20-page questionnaire in the mail afterward from the insurance company.
I finally sent it back blank, with a letter explaining that the accident was nobody’s fault, there was no lawsuit relating to the accident, and it was in fact impossible for there to be a lawsuit, because even if the accident had been someone else’s fault, we were by that point many years past the statute of limitations. After that, they finally left me alone.
One could offer a novel’s worth of additional information leading to the very same conclusion. So, no, insurance fraud is not the only reason for brevity. The question is whether more information or less information is beneficial to getting them off my ass.
Health administration student here. I literally just got home from a class in which this very practice was discussed and explained.
Yes, they are trying to figure out whether worker’s comp or someone else’s insurance should be on the hook for the bill. Call them promptly and answer their questions without being a smart-ass. I learned today that the next step, if you don’t respond, is for the medical center to send you a bill for the full cost of your treatment, as if insurance rejected your claim. It’s how they pressure you to respond. If you jump through their hoops, they should pay your claim with no problem. If not, they will give you a hard time.
The location of where and how you injured yourself is also pertinent to insurance claims.
Yeah, I would suggest that you stonewall these guys, let your insurance company put a hold or even deny your claim, so you have to pay out of pocket yourself. :rolleyes:
It depends, but usually.
If you have a broken ankle the investigation will stop.
If you had a stab wound in your house the investigation will continue.
Agree with the other posters. Tell the truth.
More generally, if TPL is involved involved insurance will usually find out anyway. Hospitals use special codes to tip off payers that TPL might be involved.
It depends, but usually.
If you have a broken ankle the investigation will stop.
If you had a stab wound in your house the investigation will continue.
Agree with the other posters. Tell the truth.
Agree the amount of money involved determines how far a case will be pursued. Sprain your ankle in a Walmart and usually the claim will be paid once Walmart denies TPL. Need orthopedic surgery and the company lawyers will get involved. (Except for auto, I’ve never seen TPL initially take responsibility.)
More generally, if TPL is involved involved insurance will usually find out anyway. Hospitals use special codes to tip off payers that TPL might be involved.
That reply is a conclusion and they almost certainly want to reach their own conclusion. They would likely regard that answer as evasive.
It is as if, when being questioned by the police about a crime, simply said “I’m not guilty” and expected that those magic words would suffice (“hey I could give a novel’s worth of information…” They want the novel.)
This is often an issue where someone injures themselves at a friend’s house. They don’t want their friend sued and they simply collect from their health insurance. Unfortunately, the folks at the health insurance company are not so generous. In your contract with them you agreed to cooperate with them in any such situation.
It’s not a requirement. My take is that Stringbean has received whatever care is necessary, and any care provided is not in jeopardy. If that’s true there is no benefit to communicating with them - they are attempting to subrogate the claim. You can help them, but you don’t have to.