Insurance Coverage Options for the Traumatically Brain Injured (Part1)

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

Perry Fisher has over 20 years of experience and specializes in traumatic brain injury. P. Fisher�s North Carolina law firm provides personal attention and takes the burden of the legal issues off the shoulders of their clients. Only a specialized brain injury attorney can effectively resolve his clients' problems.

Insurance Coverage Options for the Traumatically Brain Injured (Part1)

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