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Paying the Bills: Health Insurance, Disability Pay, and Attorneys

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Garry Prowe, Brain Injury Success Books

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Paying the Bills: Health Insurance, Disability Pay, and Attorneys

This chapter on paying the bills is excerpted from Garry Prowe's book, Successfully Surviving a Brain Injury: A Family Guidebook.

In 1997, Garry's wife, Jessica, sustained a severe brain injury in an automobile crash. "At the time, I spent way too much time accumulating the information I needed, not only to understand the medical aspects of Jessica's brain injury, but also to handle the myriad insurance, financial, legal, personal, and family issues that accompany a serious blow to the brain. I recognized the need — that stil exists today — for a book that comprehensively addresses the wide variety of issues families face in the first few months after a brain injury.

"To research this book, I assembled a panel of more than 300 survivors, caregivers, and medical professionals who resonded to my email questions and reviewed portions of my writing.

"For us, this project is a labor of love. All profits fromt he sale of this book will be donated to brain injury organizations."

* * *

If you haven’t already begun thinking about your household finances, now is the time. You need to minimize the amount of money going out for medical expenses and maximize the amount coming in through disability pay. To accomplish this, you may want to hire an attorney. This chapter helps you sort through these issues.

Health Insurance

When it comes to treating survivors of a brain injury, our health care system is unkind and shortsighted. The medical costs of recovery and rehabilitation can be astronomical. A patient with a severe brain injury and her health insurer easily can spend millions for her care. Acting early to understand the costs you are facing and the insurance benefits available to your survivor may help you avoid financial distress.

Health insurance — if you have it — generally covers much, if not most, of a survivor’s medical care during the acute stage of recovery. Then, it gets tricky. To recover well, every survivor of a serious brain injury must undergo extensive rehabilitation. This includes the standard physical, speech, occupational, and neuropsychological therapy, plus the newer cognitive rehabilitation.

In Confronting Traumatic Brain Injury: Devastation, Hope, and Healing — a forceful indictment of government, insurance, and medical policy regarding brain injury — William J. Winslade writes that most survivors do not receive adequate rehabilitation. This is shortsighted, he argues, since “a relatively few dollars spent on rehabilitation could make the difference between a life of dependency and one of relatively full function.”

With their eyes on the bottom line, health insurers limit what they pay for rehabilitation, both inpatient and outpatient. They typically pay for just two to six weeks of inpatient rehabilitation. Even worse, they sometimes insist that inpatient rehab be completed within a certain period of time, within ninety days of the injury, for example. This can be a big problem if your patient is slow to emerge from her coma.

With outpatient rehabilitation, health insurers usually cap the number of reimbursable physical, speech, and occupational therapy sessions at twenty-five to fifty per year or, even worse, per injury. With cognitive rehabilitation, they are even stingier.

The impairments most disabling to most survivors of a brain injury are deficits in attention, concentration, memory, problem-solving, and decision-making. Cognitive rehabilitation is the best way to remediate these complaints. Insurance companies, however, often deny payment, claiming that there is no evidence that cognitive rehabilitation is effective. Recent research, however, has concluded otherwise and the Brain Injury Association of America is leading the fight to have cognitive rehabilitation recognized by the insurance industry as standard, reimbursable treatment for a brain injury.

Many health insurance policies also have lifetime benefit caps, such as $1,000,000, that are easily exceeded with a serious brain injury. Caregivers often find that just when their survivor is benefiting the most from rehabilitation, the insurance company says, “No more.”

Every rehab program has a case manager who negotiates with the health insurer over the amount of reimbursable services. Your survivor is best served if the case manager at the rehabilitation facility you select has many years of successful experience working with health insurers.

  1. If you fear that your health insurance benefits may be lacking, consider these nine ways to maximize them:
  2. If you have not already informed your survivor’s health insurer about her injury, do it now.
  3. If you have not been assigned a case manager at the hospital or rehab facility, ask for one.
  4. Cultivate a good working relationship with this person.
  5. Review your policy carefully, or
  6. Have an insurance expert, an independent case manager, or an attorney who specializes in personal injury litigation review your policy.
  7. Ask about extra-contractual or going-out-of-contract exceptions that may be mutually beneficial to insurer and patient. For example, all parties involved may agree that it’s best to cut short inpatient rehab provided the insurer picks up the tab for seventy-five, rather than fifty, annual outpatient rehab sessions. Be sure to get any extra-contractual agreements in writing.
  8. Be sure your doctors are documenting all progress in your family member’s condition, even the tiniest. Health insurers are quick to stop payment if the patient is not progressing.
  9. If you feel your insurer is not treating you fairly, file an appeal with the company.
  10. If your appeal is denied, speak to an attorney.

When your health insurer says, “No more,” check out these potential sources of financial assistance for your medical bills:

  • Medicaid, if your income and financial assets are small (See page 120.)
  • Hospital patient assistance programs for people with low incomes: Talk to the hospital billing department. They may work with you to establish a payment plan you can afford.
  • Medicare, if your survivor qualifies for Social Security Disability Income: Medicare benefits, however, don’t begin until two years after the injury. (See page 121.)
  • Auto insurance, if the injury was the result of a car accident
  • Workers’ Compensation, if the injury occurred at work (See page 132.)
  • Homeowners insurance, if the injury occurred at your house or someone else’s

From Sucessfully Surviving a Brain Injury: A Family Guidebook by Garry Prowe, Brain Injury Success Books, © 2010 Garry Prowe. Used with permission. www.BrainInjurySuccess.org. You can contact Garry at info@braininjurysuccess.org.

Comments [6]

Because I had an ABI due to medical negligence, I or a family member should have contacted a lawyer immediately. However, in my case, no one took that step on my behalf. I was not fully aware of my own life altering injuries. Because the doctors/hospital were not forthcoming with my condition or the causes, and because others repeatedly told me "I was lucky to be alive!" or worse, "You look fine! "; I was hesitant to contact a lawyer. My husband is also a TBI Survivor and was incapable of supporting me emotionally/mentally. By the time I fully realized how much I had lost and found the confidence to contact a lawyer, I had missed the deadline to file suit by two weeks! We are now struggling financially as neither of us are able to work. We are both on SSDI but because my husband draws a small pension we do not qualify for Medicaid or any other services. It is incredibly difficult to understand why we cannot qualify for a desperately needed personal care assistant because my husband worked hard and managed to retire early after his brain injury. It has been suggested that he should divorce me so that I can qualify for the benefits I need. Ridiculous!

Mar 13th, 2015 4:18pm

Just wanted to say ty from a person that is recovering from tramatic brain injury ty so much someone who know how we feel

Jan 24th, 2015 9:25pm

Very well written story. It will be beneficial to anybody who employs it, including me. Keep doing what you are doing. Looking forward to more posts.

Oct 19th, 2013 4:45am

This information should be printed out and as soon as someone sustains a brain injury, the family should be told. Having survived a severe TBI August, 1997, it is in my opinion that an attorney is the best way to go...there are specific TBI attorneys now. You have included that information. In 1997, When I was hurt, there was nothing out there. I was hit by an uninsured motorist that was slapped on the wrist and fined $200...I was in a coma at 27yrs. of age and my family had to make all my decisions for me. It was 14yrs after my accident that I was approved for SSDI. What you say is true about the retroactive rules, which was a blessing. However, that doesn't last, especially in todays economy. It is by faith that I make it. Somehow the Lord always comes through for me now.

Aug 9th, 2013 1:21pm

I was hit by a car before US Navy service in Dec. 1999 and never recieved proper care due to "No-Fault" papers. I was forced into a trauma center mental health ward or two months back in 2002 which never gave me an income. I finally had to contact the Navy in 2008 referring me to a Vet Center. Now they are bullying me around because I am not originally from VT. I should be able to sue someone. Why did this kid never even lose his license and I have permanent brain damage? They closed the stupid hospital down because they were incompetant (Mary McClellan/Dr. Pitt).

Jan 27th, 2012 5:33pm

This book has been the most helpful to me since my husband\\\'s injury in June, 2011. One issue we are facing that is quite disturbing is in the area of underinsured motorist coverage. The girl who hit my husband was not insured and the owner of the car had limited liability insurance ($15,000). This is where UIM coverage is supposed to help. However, some medical insurance companies have the right to subrogate against UIM coverage and ours is one of them. We are in a situation of having to fight for money we paid premiums for - against an insurance company we paid premiums to. It is mind-boggling. I think this book cautions that a TBI can bankrupt some families - when I read that just a couple of weeks post-injury, I thought, \\\"Well, that won\\\'t be us - we\\\'ve planned for such a time as this.\\\" Guess what? This incident just may bankrupt us, and all because the insurance industry has a strong lobby in Washington. We need that UIM coverage to get my husband the rehabilitation that he needs and yet we may never see a dime of it. Check your policies and make sure this disaster doesn\\\'t happen to you.

Jan 9th, 2012 6:58pm

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