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Coping with Mild TBI: Finances Diane Roberts Stoler, EdD, and Barbara Albers Hill, Avery, Penguin Group (page 2 of 5) Page 2 of 5

Dealing with insurance companies and/or government agencies can be one of the most difficult and frustrating aspects of an MTBI. Payment for injury is a billion-dollar business that employs thousands of doctors, attorneys, investigators, consultants, and office personnel. When you become involved in this system, you become a case number in a huge maze. It is important to bear in mind that just because you have been the victim of a traumatic brain injury, you do not have to become a victim of bureaucracy and corporate decisions. Remember that insurance companies are in business to make a profit, and that these institutions deal daily with people who want to take advantage of the system. As you pursue your case, you are likely to encounter delays, tremendous amounts of paperwork, and a certain lack of sensitivity to your needs, so it is important to enlist someone — a family member, a trusted friend, or someone from your local brain injury association — to be a personal advocate who will work with you on your behalf. In addition, it is often advisable to secure the services of an attorney. (See Finding the Right Attorney, further in this chapter, for help in your search for appropriate legal counsel.) In this section, we will look at the various possibilities for financial compensation.

Automobile Insurance

Automobile insurance is designed to deal with responsibility, liability, and medical aspects of a car accident. In some states, a determination must be made as to who was responsible for causing an accident before a claim for compensation can be settled. Traditionally, damages are paid by the insurer of the party determined to be at fault. Many states have sought to simplify this process by passing so called "no-fault” insurance laws. Under no-fault insurance, each person's policy covers expenses incurred. If it can be established that one party is more than 50 percent at fault in the accident, his or her insurance company then assumes full financial responsibility.

There are three types of damage compensation that you may qualify for after an auto accident:

1. Special damages. These provide reimbursement for your medical expenses and compensation for lost wages.
2. General damages. These reimburse for what you could have earned if you had not been injured, and provide compensation for emotional pain and suffering cause in your daily life.
3. Punitive damages. Punitive damages may be assigned by the court if an insurance company fails to issue a reasonable settlement on a valid claim.

Most automobile-insurance policies have liability coverage to protect against both bodily and property damage. This will pay for damages you may cause someone else. If you live in a state with no-fault laws, you may have personal injury protection (PIP), which can cover both loss of wages and medical payments. In states with fault-based insurance laws, there is a similar type of coverage called MedPay for medical bills. Your insurance agent can provide specifics about the coverage afforded by your policy. Depending on where you live, you may also be able to purchase additional insurance to protect yourself against accident or injury caused by an uninsured motorist.

Following an accident, your first step should be to call your insurance agent — the same day, if possible. If you have sustained injuries from an auto accident and it is clearly not your fault, the insurance company will assign one of its own lawyers to act on your behalf. In many situations, if the details of what happened are clear-cut, you do not need to obtain your own lawyer. In other cases, your insurance company will advise you to do so. Most claims for medical compensation, suffering, and the like are negotiated between the insurance companies or settled out of court between lawyers. If your or the other party's insurance company questions the circumstances of an accident, it is imperative that you obtain private counsel.

Have your attorney and your personal advocate look at any proposed settlement with your or the other party's insurance company before you agree to it. Remember that symptoms do not always arise immediately after MTBI and that your injury may have affected your judgment.

Health Insurance

If your MTBI occurred as a result of a fall or sports injury, your medical expenses may be covered under your health-insurance policy. The extent of payment depends on the type of policy you have, the coverage it provides, and the amount of mandatory copayments, if any. Many policies require you to choose doctors and medical facilities from among those participating in the health plan, which may mean choosing among healthcare providers who lack specific training or experience in treating MTBIs. In most situations, health insurance companies resist paying for care provided by practitioners outside their own networks, even though this can have a negative effect on the recovery process. However, a health-maintenance organization or preferred-provider association may allow outside consultations if you can prove that your health needs cannot be met otherwise.

The first step in arranging for care outside your health-plan network is to consult your primary care physician. If he or she agrees that there is no one in the managed care network to help you, then he or she should make a referral to an appropriate person outside the network. If your primary care doctor refuses to make an outside referral because he or she will be penalized financially for doing so, you can see a doctor of your own choosing. In this situation, however, you will have to pay the outside doctor's cost yourself. You should then consult with your lawyer about including this bill in your settlement.

Available coverage and services usually depend on the health coverage you or your employer held prior to your accident, or what is covered under workers' compensation or the other party's policy. Some policies cover occupational therapy, chiropractic and psychological services; some do not, or have strict limits on such coverage. Only in the past few years has alternative insurance that covers such services as acupuncture become available.

Finding the Right Attorney

It is often advisable to hire an attorney to help you through the process of securing compensation for your injury. Without legal help, this process may be exceptionally difficult for a person with MTBI, who looks fine but whose poor judgment places him or her at an enormous disadvantage before the process is even started.

From Coping with Mild Traumatic Brain Injury by Diane Roberts Stoler, EdD, and Barbara Albers Hill, published by Avery, the Penguin Group. Copyright © 1998. All rights reserved. http://us.penguingroup.com. Dr. Diane Roberts Stoler can be contacted via her website: http://www.drdiane.com/.

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