Introduction to biomechanics


Insurance Coverage Options for the Traumatically Brain Injured (part1)

Once the acute care period is over and thetreating medical professionals should be
patient is stabilized, the resourcesaware of the impact of their patient's
available to the patient can substantiallylifetime limit coverage limits and request
impact treatment and recovery. In a perfectthreshold notification from the insurance
world, every patient would have unlimitedprovider as the threshold of the coverage
access to the best resources available tolimitation  is  approached.
meet their needs. Ours unfortunately is not
a  perfect  world.2.Subrogation  Clauses
The consequences of a traumatic brain injurySubrogation clauses appear in some insurance
are far reaching. Not only are therepolicies. A subrogation clause allows the
treatment costs associated with the recoveryinsurer the right to take legal action
from the acute injuries, but there are theagainst a third party responsible for a loss
costs of long term care and supervision, theto an insured for which a claim has been
lost support to the family unit that thepaid. The clause takes its name from the
injured party previously contributed, thesection of the policy which gives the insurer
increased physical demands placed upon thethe right to be subrogated to, or take as its
caregivers and family of the survivor to meetown, the insured's claim and to sue the
the needs of their injured loved ones, andperson or entity causing the injuries for the
the family having to step into the breach ofdamages. An insurance carrier may only sue
the role that the injured person previouslyin the name of the insured if the insured had
contributed  to  the  family.a deductible and therefore a personal stake
in the outcome of the litigation. Few health
This analysis will focus on health insuranceinsurance policies have true subrogation
sources of funding for treatment andclauses.
assistance to the traumatically brain
injured.3.Therapy  Benefits
Secondary Payors stand behind the patient toPolicies often have different caps and
pay all or a portion of the patient's medicalcoverage's for therapy benefits. Coverage's
expenses depending upon coverage and policyfor therapy benefits need to be explored and
limitations. Healthcare providers arethe therapy services properly coded in order
familiar with the process of confirmingto insure reimbursement for these much needed
coverage in advance of medical procedures andmodalities.
I will not be addressing those issues here.
Also, I will not address appeals from denial4.Home  Care  Benefits
of coverage for medical procedures as those
appeals are often dependent upon the preciseIf a patient has long term care insurance,
language of the policy and the partiesthat will often cover home care benefits.
involved  in  the  decision  making  process.Long term care insurance benefits, while
often purchased by the elderly, apply to all
A.Health  Insurance  Coveragepersons meeting the coverage definitions.
Traumatically brain injured individuals often
The health insurance coverage which a patientmeet the coverage definitions of long term
has can make a dramatic difference in thecare  insurance  benefits.
care which is available to the patient who is
unable or unwilling to pay for the services5.Veterans  Administration  Benefits
directly. The type of insurance the patient
has becomes most noticeable once the patientIf your patient was in the military, and
has  stabilized.certain covered spouses, they may be entitled
to Veterans Administration benefits. The
1.Lifetime  Coverage  LimitsVeterans Administration contracts with some
nursing homes to provide for residents
Most insurance companies have insurancecovered  by  the  VA  Program.
policies that establish lifetime limits on
coverage. Be aware that procedures which are6.Durable  Medical  Equipment
covered may become uncovered once the
lifetime limit has been reached. It is notThere is often separate coverage under most
uncommon for lifetime limits to be reached inpolicies for the provision of durable medical
treating catastrophic injuries. Families andequipment.



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