| Once the acute care period is over and the | | | | treating medical professionals should be |
| patient is stabilized, the resources | | | | aware of the impact of their patient's |
| available to the patient can substantially | | | | lifetime limit coverage limits and request |
| impact treatment and recovery. In a perfect | | | | threshold notification from the insurance |
| world, every patient would have unlimited | | | | provider as the threshold of the coverage |
| access to the best resources available to | | | | limitation is approached. |
| meet their needs. Ours unfortunately is not | | | | |
| a perfect world. | | | | 2.Subrogation Clauses |
| | | | |
| The consequences of a traumatic brain injury | | | | Subrogation clauses appear in some insurance |
| are far reaching. Not only are there | | | | policies. A subrogation clause allows the |
| treatment costs associated with the recovery | | | | insurer the right to take legal action |
| from the acute injuries, but there are the | | | | against a third party responsible for a loss |
| costs of long term care and supervision, the | | | | to an insured for which a claim has been |
| lost support to the family unit that the | | | | paid. The clause takes its name from the |
| injured party previously contributed, the | | | | section of the policy which gives the insurer |
| increased physical demands placed upon the | | | | the right to be subrogated to, or take as its |
| caregivers and family of the survivor to meet | | | | own, the insured's claim and to sue the |
| the needs of their injured loved ones, and | | | | person or entity causing the injuries for the |
| the family having to step into the breach of | | | | damages. An insurance carrier may only sue |
| the role that the injured person previously | | | | in 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 insurance | | | | insurance policies have true subrogation |
| sources of funding for treatment and | | | | clauses. |
| assistance to the traumatically brain | | | | |
| injured. | | | | 3.Therapy Benefits |
| | | | |
| Secondary Payors stand behind the patient to | | | | Policies often have different caps and |
| pay all or a portion of the patient's medical | | | | coverage's for therapy benefits. Coverage's |
| expenses depending upon coverage and policy | | | | for therapy benefits need to be explored and |
| limitations. Healthcare providers are | | | | the therapy services properly coded in order |
| familiar with the process of confirming | | | | to insure reimbursement for these much needed |
| coverage in advance of medical procedures and | | | | modalities. |
| I will not be addressing those issues here. | | | | |
| Also, I will not address appeals from denial | | | | 4.Home Care Benefits |
| of coverage for medical procedures as those | | | | |
| appeals are often dependent upon the precise | | | | If a patient has long term care insurance, |
| language of the policy and the parties | | | | that 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 Coverage | | | | persons meeting the coverage definitions. |
| | | | Traumatically brain injured individuals often |
| The health insurance coverage which a patient | | | | meet the coverage definitions of long term |
| has can make a dramatic difference in the | | | | care insurance benefits. |
| care which is available to the patient who is | | | | |
| unable or unwilling to pay for the services | | | | 5.Veterans Administration Benefits |
| directly. The type of insurance the patient | | | | |
| has becomes most noticeable once the patient | | | | If your patient was in the military, and |
| has stabilized. | | | | certain covered spouses, they may be entitled |
| | | | to Veterans Administration benefits. The |
| 1.Lifetime Coverage Limits | | | | Veterans Administration contracts with some |
| | | | nursing homes to provide for residents |
| Most insurance companies have insurance | | | | covered by the VA Program. |
| policies that establish lifetime limits on | | | | |
| coverage. Be aware that procedures which are | | | | 6.Durable Medical Equipment |
| covered may become uncovered once the | | | | |
| lifetime limit has been reached. It is not | | | | There is often separate coverage under most |
| uncommon for lifetime limits to be reached in | | | | policies for the provision of durable medical |
| treating catastrophic injuries. Families and | | | | equipment. |