Health Insurance Penalty Clauses

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Health insurance policies differ in what they will cover when a patient has a personal injury claim. Many health policies limit or exclude chiropractic, naturopathic, massage, or acupuncture. Some health policies offer no coverage at all for motor vehicle injuries.

Most health policies cover medical expenses for motor vehicle injuries only after receiving verification that PIP benefits have been exhausted, and the health carrier will be entitled to be reimbursed through a lien on the patient’s personal injury claim. Health insurers usually want the patient – and the patient’s attorney – to agree in writing to reimburse the carrier for medical benefits related to a patient’s personal injury claim.

Sometimes medical bills should be sent to the health carrier, other times not. Administrative dealings with health insurers are often complex and time-consuming, and can disrupt the patient’s claim rather than help it. Some health insurers that pay medical benefits related to a personal injury claim will restrict future benefits for those injuries. The patient and the provider should weigh the current medical expenses against future medical expenses, and make sure they know whether future health benefits might be at risk.

Providers should consider contacting the patient’s attorney to determine whether to bill the health carrier.

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