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Co-pay and other question

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tobacco road

Junior Member
What is the name of your state? NC

My Girlfriend was in an Accident 2 months ago, and she's been seeking therapy and neck and back treatment. One of my questions is we've been paying the dr visits( surgeon, xrays, medicines etc..) with our own co-pay insurance. Eventhough the at fault ins company stated they will pay on reimbursement, to me it seems they are getting off easy. We pay the copay. 12.00 ok, the Dr or whomever bills our ins company for whatever amts.. lets say for this visit the Dr fees are 245.00.

Now the Ins company is only paying our co-pays back to us where as the dr and his services are billing "our insurance" company full price. So in time the at fault insurance company reimbursements will be small. Should I alert my Ins company so they can be aware or what?

Plus we have no attorney, thinking we could maintain the process ourselves( may be crazy) we've kept all records, lost wages, medicine and the ongoing therapy treatments. We've not thought to get an attorney, but now they've said these shots and treatments aren't going to well, so we're looking longterm and just don't want to screw ourselves by not knowing or not doing something. An Attorney still probably not needed considering 30-40% fees, but we're just nervous.
 
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Cosmot0731

Junior Member
Yes I would definately notify your insurance company that these injuries were the result of an auto accident and give the claim number and company involved. They will bill the auto insurance company as they are the ones responsible for the bills.

Sounds like the claim is going ok, so an attorney at this point might be premature. The other reason for notifying your health insurance carrier is that you need to be very open and up front about your injuries from the accident and about how long the treatment should continue. I'm not saying to down play your injuries but your doctors will continue to update the auto ins co regarding the status and outlook for recovery. As long as your doctors feel that your injuries are not fully healed (ie:sometimes physical therapy can go on for years) and you are honest about how you are feeling, then as long as the auto ins co is paying, you can probably wait on the attorney.
Remember that the auto ins co will want copies of your medical records.

You can always get a lawyer at any point that you feel the auto ins co is being unreasonable, especially when it comes time to settle. If your injuries were severe and ongoing then it is not unreasonable to ask for pain and suffering. This won't be tons of money, just something out of good faith. Most good ins co's will give you a reasonable settlement since they know that if you did get an attorney, their out of pocket money goes way up.

Good luck
 
T

tobacco road

Junior Member
Thanks... yeah we defintetly wondered on alerting, because I tell you these copays are mounting up.. mean 12.00 is not much, but when you're doing them 3 and 4 times a day. And we don't want to get penalized if we go over some usage or they find out later this was something that should've been alerted.

Yes we have no problems on the medical records, as they sent a form for release of information that we havent return yet(by error) We've been upfront and honest. The Shots in the spine are very intimidating. Once we turn over the medical and they review us and the continued process, i assume they will contact for completion or settlement? Up to this point we've had no problems with them. Knock on wood..
 
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DGO1223

Member
Insurance providers are in the business to MAKE money, not pay it out. Be ready to face a struggle to get them to pay what is fair for everyone involved.

If any of the Dr.'s think these injuries are going to involve more of a long term type thing, depending on the severity, you may need a lawyer of your own to sort it all out. There are too many details involving trying to figure out just what any recompense is considered fair, ie future lost wages, med. treatment, long term prognosis, etc.

I WOULD NOT send them any forms for release of medical information!!! You are setting yourself up for a lot of headaches there! :eek:

You need to at least talk to someone with some legal experience on this one before doing anything else.
 
T

tobacco road

Junior Member
So the concencious is not to send the paperwork or release of medical or whatever they call it? If we don't feel it out, would the at fault insurance company hold against us or try some funny business? Last note, if we don't do the above, how do we go about settling once we feel this is correct? Does the Insurance Company pound us to settle or we say it? It's irritating because relief is not on the horizon we've had 2 of these Epidermal Shots, Therapy, and continued visit.. I've gotten a lot of info from this board and want to recap:

1. It's recommended to alert our own Insurance Company that we've been in a accident and the co-pays we're paying and the medical they are paying should be billed to the at fault insurance company?

2. Don't send the medical release form? (This one seems shaky to me) I don't want to irritate them since there have been no problems thus far. Is this a determination for them to assess the situation and do a calculated forced settlement, or arm themselves with info to sour anything positive? I'm assuming this is also part of their procedure, but again my girlfriend and me want to know what's right and wrong.
 
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InsuranceLadyAZ

Member
DGO1223 said:
Insurance providers are in the business to MAKE money, not pay it out. Be ready to face a struggle to get them to pay what is fair for everyone involved.

If any of the Dr.'s think these injuries are going to involve more of a long term type thing, depending on the severity, you may need a lawyer of your own to sort it all out. There are too many details involving trying to figure out just what any recompense is considered fair, ie future lost wages, med. treatment, long term prognosis, etc.

I WOULD NOT send them any forms for release of medical information!!! You are setting yourself up for a lot of headaches there! :eek:

You need to at least talk to someone with some legal experience on this one before doing anything else.
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The OP hasn't indicated there have been any problems with getting bills paid, so why should they refuse to release the medical records to the insurer, who has a right to know what medical services they are paying for?

Sign the release and send it to the insurance company. Don't create a problem where there isn't one currently.
 
D

DGO1223

Member
InsuranceLadyAZ said:
The OP hasn't indicated there have been any problems with getting bills paid, so why should they refuse to release the medical records to the insurer, who has a right to know what medical services they are paying for?

Sign the release and send it to the insurance company. Don't create a problem where there isn't one currently.
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Understandable advice coming from an insurance agent. Nothing derogatory intended in that statement either. Hopefully someone with legal experience here can chime in with better advice than mine.

You should have already told your insurance company about this accident! Why didn't you? Maybe they can advise you somewhat on this, but I would not count on it.

And yes, the other ins. will arm themselves with any medical information they can dig up, and can use it against you at some point if they want to get nasty about it. Been there.

They also have lawyers willing to fight against paying you if come up with some steep medical bills they think are unreasonable.

What I wrote is my opinion only, based on experience and what I was advised by my lawyer concerning an accident with injuries.

He also told us NOT to sign ANYTHING without his approval first. BTW, he is a family friend, and not out to gouge money from anyone.

Please keep us posted and let us know what you decide to do, I would be interested to know, and what the outcome is.

Maybe there are some company's out there who are willing to treat you fairly, I hope so in your case.
 
T

tobacco road

Junior Member
My head is spinning Now.................... DGO1223 We Did alert our Auto Insurance Company , but that was only before the At fault admitted and then we never processed the claim. So The Insurance Company I'm speaking about is my girlfriends Medical Provider at her Job, not her Auto Insurance Carrier. I figured they'd armed themself, but everything is legit and stems from the accident. I will keep posted, knew we were out of our league, and needed some advice on whether our steps are inline, or off base, as well weigh whether an attorney or legal rep is needed at this stage. This information has been invaluable
 
D

DGO1223

Member
tobacco road said:
My head is spinning Now.................... DGO1223 We Did alert our Auto Insurance Company , but that was only before the At fault admitted and then we never processed the claim. So The Insurance Company I'm speaking about is my girlfriends Medical Provider at her Job, not her Auto Insurance Carrier. I figured they'd armed themself, but everything is legit and stems from the accident. I will keep posted, knew we were out of our league, and needed some advice on whether our steps are inline, or off base, as well weigh whether an attorney or legal rep is needed at this stage. This information has been invaluable
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Oh, so it's her med. insurance, I see. I thought you mean the other driver's!! Sorry.

Yes, I'm sure there is no reason why you can't give them that info. When this is all over, they will want to be re-imbursed for their payments, as they are not actually responsible, the at fault parties ins. is.

While we are going thru something similar, all the insurance responsibilites and legal ins and outs are confusing. We've even had a surgeon's office refuse to do surgery without $$$$ upfront, because they don't want to be left out on payment!

We had to put $1,050 on a credit card to pay them part of it. Now, we filed it and our med. ins. paid THEM, and they owe US $$$ now!!!! Long story there.

That's why we just threw in the towel and let a lawyer deal with it. It's not worth the misery and aggravation sorting it all out. I simply take everything to his office and let them handle it.

It's simply out of our league, and we don't want to be sorry later. Plus the fact that my husband was injuried more seriously than first thought.

Try to at least speak with a lawyer or his office on the phone and see what they say. They may tell you it sounds simple enough for you to take care of yourself. Or they may say you can come in for a consult. Usually they are free.

Whatever you decide, good luck with it. Hang in there. :)
 
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InsuranceLadyAZ

Member
DGO1223 said:
Understandable advice coming from an insurance agent. Nothing derogatory intended in that statement either. Hopefully someone with legal experience here can chime in with better advice than mine.
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Somebody already did. FYI, I don't always side with the insurance carrier. However, not every claim has to be escalated to the level of a lawsuit. The OP should allow the carrier to take care of the claims, as they've already been doing. If a problem arises, she certainly has the right to seek legal counsel.
 
D

DGO1223

Member
InsuranceLadyAZ said:
Somebody already did. FYI, I don't always side with the insurance carrier. However, not every claim has to be escalated to the level of a lawsuit. The OP should allow the carrier to take care of the claims, as they've already been doing. If a problem arises, she certainly has the right to seek legal counsel.
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I'm sorry, I did not know anyone had answered that had legal experience. I apologize.

No, no need to escalate this into some sort of lawsuit; I just wanted the OP to be aware of possiblities. When it gets too confusing, it's better to be safe than sorry, then regret it later.

Unforunately, I know of too many cases of innocent, trusting victims who signed away their rights by trying to do the right thing, myself included. Hard lesson learned. :(
 
T

tobacco road

Junior Member
Why would my girlfriends Ins Co want to be reimbursed? We are only using it becuase she has insurance. We didn't want to pay using our "Cash" or Credit Cards. So you're saying there's a possibility her insurance provider( HMO) will want to be reimbursed? The At Fault Insurance Company had stated they would reimburse her of any charges medical & pain/suffering. Anyway I think using her Provider was a better option than either not having Ins or trying to get the Dr's & Phy therapist to Bill the at fault Insurance company. We tried that at first and the Dr said they dont' bill third party. We're just ready to bedone with all of this, but not in a haste and later realize she's not well or mess up. Steady as she goes huh.....
 
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DGO1223

Member
tobacco road said:
Why would my girlfriends Ins Co want to be reimbursed? We are only using it becuase she has insurance. We didn't want to pay using our "Cash" or Credit Cards. So you're saying there's a possibility her insurance provider( HMO) will want to be reimbursed? The At Fault Insurance Company had stated they would reimburse her of any charges medical & pain/suffering. Anyway I think using her Provider was a better option than either not having Ins or trying to get the Dr's & Phy therapist to Bill the at fault Insurance company. We tried that at first and the Dr said they dont' bill third party. We're just ready to bedone with all of this, but not in a haste and later realize she's not well or mess up. Steady as she goes huh.....
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They are due reimbursement because they are not ultimately responsible for these charges; the at fault's insurance that will be paying up at settlement is responsible. That's why there is such a thing as auto insurance!

Look at it this way; if the other drivers insurance paid you, you would be getting double payment, because both would have paid.

Thus the auto insurance pays back the medical bills. You would only be paying co-pays out of your pockets, which you should be able to get back from their auto insurance. All things being equal, you are left paying nothing, except time lost from work, pain & suffering, etc.

That's where the auto insurance offers to make you a settlement. You need to make sure they have reimbursed all the medical providers, and her medical insurance their money. THEN, whatever is left is hers to keep.

ASSUMING everything all goes smoothly and fair.
Your GF then has to decide what she thinks is fair for her to accept from them for all this, and the insurance agrees.

Our hospital immediately placed a lein against our at fault drivers insurance; they would not file it with our med. insurance. They are greedy, simply because they would rather receive FULL payment for their charges, not what our med. would have paid them; because they would have gotten paid contract prices from them, since they are on our plan.

In a perfect world, all the providers are paid, and she is paid what she thinks is fair for her pain and suffering, and inconvenience. Then everybody is happy.

Does this make sense now? Do you see why I think it can get complicated?

Do yourself a favor; in order to set your mind at ease, call a lawyers office and ask them what they think.
 
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InsuranceLadyAZ

Member
DGO1223 said:
They are due reimbursement because they are not ultimately responsible for these charges; the at fault's insurance that will be paying up at settlement is responsible. That's why there is such a thing as auto insurance!

Look at it this way; if the other drivers insurance paid you, you would be getting double payment, because both would have paid.

Thus the auto insurance pays back the medical bills. You would only be paying co-pays out of your pockets, which you should be able to get back from their auto insurance. All things being equal, you are left paying nothing, except time lost from work, pain & suffering, etc.

That's where the auto insurance offers to make you a settlement. You need to make sure they have reimbursed all the medical providers, and her medical insurance their money. THEN, whatever is left is hers to keep.

ASSUMING everything all goes smoothly and fair.
Your GF then has to decide what she thinks is fair for her to accept from them for all this, and the insurance agrees.

Our hospital immediately placed a lein against our at fault drivers insurance; they would not file it with our med. insurance. They are greedy, simply because they would rather receive FULL payment for their charges, not what our med. would have paid them; because they would have gotten paid contract prices from them, since they are on our plan.

In a perfect world, all the providers are paid, and she is paid what she thinks is fair for her pain and suffering, and inconvenience. Then everybody is happy.

Does this make sense now? Do you see why I think it can get complicated?

Do yourself a favor; in order to set your mind at ease, call a lawyers office and ask them what they think.
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Yes, by all means. Call an attorney. File a completely uneccesary lawsuit, when the insurer is already paying what's required of it under the terms of the policy, because our courts don't have enough frivolous suits already.

Your health insurance wants to be reimbursed because they should be reimbursed. The purpose of insurance is to make you whole, not for you to turn a profit by being reimbursed for expenses that didn't come out of your pocket. The only medical payments you're entitled to are your out-of-pocket expenses.

I fail to understand why you think the HMO shouldn't be reimbursed.
 
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