You're injured. Who pays?
- By Milt x_Zall
- May 28, 2001
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].