Legal/Insurance terms - Subrogation Claim?

Factual Questions
1

Yes I’ve googled this, yes I know I’m dense.

Please explain wtf this is?

About 9 months ago, I was in a car accident (I was not at fault) and required some medical treatment. I paid a shitload of it myself for my deductible, and from what I can tell from my paperwork, the other dude’s car insurance company, or my car insurance company (the same company, fwiw) paid the rest of it.

Now my *medical *insurance is sending me a Subrogation alert, saying that I owe THEM money for their previous payment for part of all that.

I don’t get it. :stupid puzzled face:

Personal Interest Questions:
How do I find out if that’s true?
Why aren’t they hassling the other dude (the one who caused the accident in the first place) about this money?
What happens if I can’t pay them?
Do I have any legal means (which wouldn’t cost me as much as just paying them off in the first place) of appealing this charge?

General Interest Questions:
Why was my medical insurance paying out for something that presumably should have been covered by the other dude’s car insurance policy?
Why wait 9 months before sending anything to me?
Why can’t these people use standard english terminology when trying to explain why people suddenly owe them money?

2

Here’s the wikipedia entry on subrogation.

3

Thanks, but as pointed out in the OP, I already Googled (should have specified wikied) this already, and still have the above questions.

I will fully admit that the uses of x and 1-x and d and all that made my head spin. I am not a person who is good with designations. Put it into a word problem with real words and I’m fine, but the designations are throwing me off.

I just want a quick, basic english translation of what the *point *of all this is?
WHY did they do this that way? How is this possibly a good idea? Did they TELL me they were going to at any point? Could I have avoided this in any way?

4

When you went to the hospital, you gave them your health insurance card. It appears that’s who the hospital and medical personnel filed with for payment for medical services rendered. It also appears that your medical insurance paid them…somewhere along they way they determined that you were in a car accident and that those types of claims should be covered by another type of insurance…either your auto policy (which normally does include some medical coverage) or the person who was at fault.

Have you been in contact with the other party’s auto insurance carrier? If so you should have a claim #, contact them and provide them the notice from your health insurance carrier. Contact your health insurance carrier and provide them the information on the other party’s auto insurance and give them the claim #.

They are just trying to sort out the bills. You have to help them, they can’t just figure it out on their own.

5

If I were you, I’d call my doctor’s office and find out:

  • who they billed,
  • who paid what,
  • what charges, if any, are still outstanding.

When you know that, you have something to talk about with your auto insurance carrier. Let them deal with this mess themselves. If the other driver was at fault, his/her insurance should cover all your medical expenses, including what you already paid out of pocket toward your deductible.

6

This will not be over quickly. You will not enjoy this. I’m not your claim representative.
What state do you live in? That may or may not change some details of what is to follow.

Ok, here’s the general version. Apply it to your situation and you will better understand what’s up.

Car wreck. You’re injured and require medical treatment. Money for that comes from several places(in no particular order, because that’s WAY complicated):
1) Other Guy’s *bodily injury liability coverage *(which he’s required, by law, to have in order to drive a car)
2) your pocket
3) Medical Payments Coverage/Personal Injury Protection (MPC/PIP)(Something which may or may not be on YOUR car insurance policy.
4) Your personal health insurance

Stuff to know:
a) Because you were injured in a car accident, you are entitled to a bodily injury settlement. This settlement will include things like lost wages and the reasonable cost of necessary care to recover from injuries which are related to the accident.
b) For very good reasons I won’t go into here, a bodily injury settlement is a lump sum which is awarded one time. It does not (typically) pay bills as they are incurred. The bills are your responsibility and you can address them using options 2-4 above.
c) If you pay an expense for something that’s not your fault, you expect to be reimbursed. Your health insurance and MPC/PIP are no different. For them, this process is called subrogation. Subrogation is part of the contract YOU have with THEM. In exchange for receiving their protection, you agree (it’s in your insurance contract, you really should read it sometime) to allow them to recover their expenses.
d) Re-read item a). YOUR bodily injury settlement included the medical expenses your health insurance paid for.

You’ve probably figured out that I’m an injury adjuster. When I discuss a case with someone like you, and we come to a settlement agreement, I am obliged to acknowledge anyone who has come forward and said, “Hey, when you settle, I’m entitled to a chunk of that pie.” A health insurer who is bringing a subrogation demand, for example. If nobody has stepped forward, I can give it all to you. Doesn’t mean there are no subrogation interests out there (which you are contracturally obliged to honor), just means I don’t know of any. They SHOULD have put me on notice well before 9 months after the treatment, but it doesn’t always happen. So part of that bundle of cash I gave you actually belongs to someone else.

Now. If someone is demanding a chunk of your settlement from you, you have the right to know what they’re saying is related and what they paid. Get a SUBROGATION LEDGER from the medical insurance folks. This will give dates of treatment, providers, what was billed and what was paid.

You’ve probably got more questions now, but answer this: Have you settled a bodily injury claim with the other guy’s insurance yet?

7

Subrogation in general just means that one person buys a claim from another person. So, say you pay me $1, and in return I agree to pay your medical expenses if you get injured. You get injured and incur medical expenses of $100. You have a right to sue the person who injured you for $100.

I pay you $100. By that payment, I acquire your right to go after the person who injured you for $100.

Your situation is a little more complicated than the example. It looks like the medical insurance company is saying that they can go after the auto insurance company for the amount they paid since the auto insurer is resposible for paying for the injury its customer caused. However, they are essentially using you as the payment mechanism. That is, the mdical insurance company paid the hospital for amounts that should have been paid by the auto insurance company, so med wants to collect from you, and you should be able to collect from auto.

8

I suspect you are either misreading what they’ve sent you or they are explaining it poorly.

In simple terms, subrogation is a mechanism for preventing “double dip” recovery. Let’s say insurance company X and insurance company Y both paid you 2 weeks of lost wages because you couldn’t go to work due to your injuries for 2 weeks.

Under the law, you’re not entitled to 4 weeks of lost wage payments when you only missed two weeks of work, so one insurer or the other gets its money back. Which one depends on the law of your state and the types of policy.

Here, your health insurer is probably trying to recover payments made for emergency care which it now realizes are the PIP (auto accident) insurer’s responsibility.

They aren’t going to recover it from you, since you didn’t actually get the money. What you’re supposed to be doing is calling their recovery services department (or whatever their subrogation department is called, which will probably be on the letter) and passing along the information for the auto insurance company.

Specifically, they’ll want: (1) the name of the insurer, and their insured- the guy who hit you; (2) the insurer’s claim number; (3) the name of the adjuster.

They will then go after the other insurance company for you. You also need to call your insurance company and ask them why you had to pay a deductible; deductibles apply to insured parties, not third parties.

On further review, it looks like Omar already covered everything you need to know. :smack:

9

I didn’t think it would be. Yay bureaucracy.

SC

I *think *so, but I’m not sure. It’s all complicated because MY insurance company and HIS insurance company are the same company.

Yes, I did get a settlement from the insurance company, but when I talked to them (I have the transcript I kept while on the phone with them) they said that the medical bills would also be taken care of seperately, as none of those bills had appeared at the time.

10

Have you signed anything?

11

I wouldn’t be suprised to find out it was both. I’m not the best at legalese, and I have very little experience with insurance and medical billing stuff.

Now THAT is nice to know. Wish I’d known that when the doctors refused to let me go without paying them.

12

What kind of a question is that?

From who? My car insurance policy? Yes, I’m sure I signed a great deal of stuff when I first got my policy.

My medical insurance? Yes, along with all the other new-hire paperwork that gets shoved at you at a new job.

The settlement payment? Yes, I had to sign that I did in fact receive the money. and the same for the payment for my totalled car. I don’t recall either of them saying anything about limiting my ability to get payment for any other portion of the accident costs. All they referenced was the specific payment which was made then.

13

I meant stemming from the accident, rather than ever. Sorry.

Did they give you a copy of the releases you signed?

14

I was an insurance adjuster in NC for five years 1974-79 and handled several
hundred auto accident bodily injury claims.

Laws may vary from time to time and from state to state but the responsible
party must surely be liable for all of your medical expenses, plus any loss of
income, plus pain and suffering should you wish to pursue restitution to that extent.

Also, back in the 1970s if you were entitled to medical bill reimbusement from
anyone you paid premiums to in addition to anything you got from the responsible party.

I never heard of subrogation for medical expenses, and I never heard of any
kind of subrogation by a company against its own policy holder but maybe that
has changed. Subrogation took place only when property damage insurance paid
for a loss, and then sought to recover what they paid from the responsible party.

Your state should have an insurance Commissioner’sffice with staff who can
answer your questions about the subrogation situation, and any other issue
you might have. There should also be plenty of lawyers anywhere in the US
who would be glad to represent you on the injury claim.

15

No worries, didn’t mean to come off as snippy - just struck me as a funny question. I actually did LOL when I read it.

Yes, I have copies of the signed settlement payment papers at home - I open my mail at work these days since I don’t have a home office any more, and so I’ll have to get them all out when I get home.

Were you thinking of any other kind of release? The only paperwork I ever saw was about those two payments - everything else finished up without me involved, and when I followed up with the medpeople, everything was already paid off, so I figured that was it.

I didn’t think to inquire about WHO paid it off. This whole thing seems unnecessarily complicated to me.

By colonial

Yeah, that’s the other thing. Lots of people here are saying things like I have to go find the auto insurance people and forward the medical insurance info on to them, or go the other way and give the medical people the car insurance people’s contact info, and everything will come up roses while they duke it out between them.

But what they sent me isn’t a letter asking for directions or for clarification, it is an actual BILL. “Please send a check or money order for this amount (insert amount) made payable to insert insurance company.”

Which is weird, and making me a little indignant.

16

I think Inigo’s explanation made sense:

Right now you have the money you got from Mister X’s car insurance (sitting in your wallet) and you have the money you got from your own medical insurance that was used to pay your bills (paid directly to the hospital). So you effectively have gotten two payments from two insurance companies, whereas you’re only really entitled to one payment from one insurance company, and that’s why you have to pay one of them back.

(Disclaimer: I’m from Canada, so I don’t have first-hand knowledge of how the American system works.)

17

If you signed a bodily injury settlement agreement, something that says something like, “I release Inigo Montoya, his heirs, estate, etc forever from any liability and blahblahblah,” you’re done.

It sounds like the health insurer finally got around to advising the car insurance folks of their subrogation interest, and the car people said, “Too late, we already settled the claim and gave a wad of cash to Lasciel. You expenses are in that wad.” So the health insurer followed the wad.

18

Well you made a medical claim against your health insurance that was not their responsibility. You shouldn’t be indignant, they should and are and have sent you a bill to get reimbursed because you mistakenly filed a claim that was not their responsibility. You act like because you have insurance you’re magically covered and let the various insurance companies figure out who owes what. You made the mistake, you have to fix it.

19

More likely the hospital made the claim. Other than identifying the list of possible payors, a patient doesn’t have a responsibility to ensure the bills for emergency care are sent to the correct entity.

20

A subro claim is when an insurance company attempts to collect on money they paid out but it turns out they weren’t liable for. If you presented your health insurance card when you went for medical treatment after the accident, the billing dept may have put them down as your primary.

Do not worry. Do some investigation to find out which insurance company accepted and paid for your bodily injury claim. Forward the subrogation notice to that carrier. The medical facility is using a tactic that has gotten people to pay them out of pocket in the past; DO NOT pay this. Don’t get a lawyer, you don’t need one. It may take a few days of phone tag, but find out where you need to send it. The insurance company is sending the subro notice to you because they don’t want to waste time investigating who actually owes it. You’re the low-hanging fruit.

I work in insurance.

Alternatively, you could attempt to contact your OWN claim adjuster, if you filed a claim for this through your own auto insurance. Not everyone does that. And people who only have liability coverage (no collision covg) are unlikely to get an adjuster at their company to step up to the plate for them, either.