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