Introduction to biomechanics


Insurance Coverage Options for the Traumatically Brain Injured (part1)

Once the acute care period is over andlifetime limits to be reached in
the patient is stabilized, the resourcestreating catastrophic injuries. Families
available to the patient canand treating medical professionals
substantially impact treatment andshould be aware of the impact of their
recovery. In a perfect world, everypatient's lifetime limit coverage limits
patient would have unlimited access toand request threshold notification from
the best resources available to meetthe insurance provider as the threshold
their needs. Ours unfortunately is notof the coverage limitation is
a perfect world.approached.
The consequences of a traumatic brain2.Subrogation Clauses
injury are far reaching. Not only areSubrogation clauses appear in some
there treatment costs associated withinsurance policies. A subrogation
the recovery from the acute injuries,clause allows the insurer the right to
but there are the costs of long termtake legal action against a third party
care and supervision, the lost supportresponsible for a loss to an insured for
to the family unit that the injuredwhich a claim has been paid. The clause
party previously contributed, thetakes its name from the section of the
increased physical demands placed uponpolicy which gives the insurer the right
the caregivers and family of theto be subrogated to, or take as its own,
survivor to meet the needs of theirthe insured's claim and to sue the
injured loved ones, and the familyperson or entity causing the injuries
having to step into the breach of thefor the damages. An insurance carrier
role that the injured person previouslymay only sue in the name of the insured
contributed to the family.if the insured had a deductible and
This analysis will focus on healththerefore a personal stake in the
insurance sources of funding foroutcome of the litigation. Few health
treatment and assistance to theinsurance policies have true subrogation
traumatically brain injured.clauses.
Secondary Payors stand behind the3.Therapy Benefits
patient to pay all or a portion of thePolicies often have different caps and
patient's medical expenses dependingcoverage's for therapy benefits.
upon coverage and policy limitations.Coverage's for therapy benefits need to
Healthcare providers are familiar withbe explored and the therapy services
the process of confirming coverage inproperly coded in order to insure
advance of medical procedures and I willreimbursement for these much needed
not be addressing those issues here.modalities.
Also, I will not address appeals from4.Home Care Benefits
denial of coverage for medicalIf a patient has long term care
procedures as those appeals are ofteninsurance, that will often cover home
dependent upon the precise language ofcare benefits. Long term care insurance
the policy and the parties involved inbenefits, while often purchased by the
the decision making process.elderly, apply to all persons meeting
A.Health Insurance Coveragethe coverage definitions. Traumatically
The health insurance coverage which abrain injured individuals often meet the
patient has can make a dramaticcoverage definitions of long term care
difference in the care which isinsurance benefits.
available to the patient who is unable5.Veterans Administration Benefits
or unwilling to pay for the servicesIf your patient was in the military, and
directly. The type of insurance thecertain covered spouses, they may be
patient has becomes most noticeable onceentitled to Veterans Administration
the patient has stabilized.benefits. The Veterans Administration
1.Lifetime Coverage Limitscontracts with some nursing homes to
Most insurance companies have insuranceprovide for residents covered by the VA
policies that establish lifetime limitsProgram.
on coverage. Be aware that procedures6.Durable Medical Equipment
which are covered may become uncoveredThere is often separate coverage under
once the lifetime limit has beenmost policies for the provision of
reached. It is not uncommon fordurable medical equipment.



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