You're injured. Who pays?

This column is in response to a reader inquiry about subrogation — a rule that comes into play when someone is accidentally injured and needs medical care. Here's the scoop.

All carriers in the Federal Employees Health Benefits program (FEHB) apply what's called the rule of subrogation. Under this rule, the fee-for-service carriers in the FEHB can recover the cost of your health care if you sue someone who's responsible for causing accidental injury to you or a family member.

If another person causes you or a family member to suffer an illness or injury and your FEHB fee-for- service carrier pays benefits to you for that injury or illness, you are required to do the following:

n You must use all recoveries you obtain — either by lawsuit settlement or some other means — to reimburse your carrier in full for the benefits paid to you. You can keep any compensation for pain and suffering paid by the other insurance company.

n You must allow your FEHB carrier to initiate recovery on your behalf if you don't seek compensation for your illness or injury from the other insurance company.

n You must do whatever is reasonably necessary to help your carrier recover benefits that were paid to you and not take any action that would damage the carrier's ability to recover.

n You must tell your carrier if you have a claim against another person regarding a condition for which the carrier has paid or will pay, and you must tell the carrier about any recoveries you obtain either in or out of court.

n The carrier may request that you assign your right to bring an action or your right to the proceeds of a claim for an illness or injury. The carrier may delay processing of your claim until you provide it with this assignment.

n Your carrier must pay the cost of any covered service you receive that exceeds what you recover through a suit or arbitration or an out-of-court settlement.

Here are some circumstances under which an FEHB fee-for-service carrier may subrogate a payment made to you: You or your dependent is injured on property owned by someone else, or you or your dependent is injured and benefits are payable to you or your dependent under a law or some type of insurance including, but not limited to, personal injury protection benefits, uninsured and underinsured motorist coverage, workers' compensation benefits and medical reimbursement coverage.

If you or a family member is injured as described in this article, you should contact your carrier and advise your attorney that your FEHB coverage falls under the rule of subrogation. Feds who are enrolled in an HMO should contact their carrier to determine how their subrogation procedures work.

Zall is a retired federal employee who since 1987 has written the Bureaucratus column for Federal Computer Week. He can be reached at [email protected].


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