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