Does insurance pay before the doctor visit?

by Tracey
(Virginia Beach, VA)

I was coming out of a gas station store and slipped on oil built up in the parking lot. It had started to rain while I was in the store and the parking lot was wet. As I approached my car I slipped on an oil and water mixture. As I fell I felt a pop in my leg. I caught myself in the door of my car, so I didn't hit the ground.

I was in pain right away. As the day went on the pain got worse so I called the store and spoke with the assistant manager and reported it. I went to the hospital ER and they said I pulled a muscle in my leg. I was out of work for two days and was put on pain killers.

It's been five days now. I spoke with the insurance person today and she told me to come up with a figure and they would send me a check. I am still in pain and feel that I need to see a doctor, but I have no insurance and no money.

I don't know how much it will cost for the rest of the medical bills, so I can't give the insurance company a total and I can't go to the doctor without the insurance money. I'm not sure how to come up with a total so I can get the money to go to the doctor.

The insurance is only going to give me money once, therefore I need to make sure everything is covered. As I understand it, the total needs to include the emergency room bill, lost wages, future doctor visits, medication and pain and suffering. Is there anything else I should include? Thank you.

Visitor Question:
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ANSWER for "Does insurance pay before the doctor visit?":

Tracey (Virginia Beach, VA):

In a word, “Yes.” But creating a settlement demand will require a compilation of all the dollar amounts and then an attempt to incorporate them into a cohesive and realistic settlement amount. Let’s try to break it down...

Presenting your emergency room bill, lost wages, future doctor visits, medication and pain and suffering is all well and good. It's the manner of presentation which determines the amount of reimbursable compensation.

Let’s take the medical bills first. In the “business” they are referred to as “Hard Costs”. Hard Costs are tangible and measurable. Pain and suffering is not. Lost Wages are not.

To make a credible presentation in an effort to optimize your settlement you should take your Hard Costs and multiply them by an integer sufficient to cover all the intangibles. Although intangibles are by their own definition immeasurable, the art of attempting to prognosticate their future value is something which must be practiced to be effective.

We suggest you do your best to add the intangibles and do your best to gauge the future costs. Take the Hard Costs and add to them your prognostication of the intangibles.

Because Pain and Suffering is even less intangible than the intangibles stated above. Attempting to incorporate into the settlement amount a reliable figure for pain and suffering is really no more than an educated guess. You'll have to rely on your instincts to measure a sufficient amount.

Once you are satisfied with the total amount, you should be ready to make your initial settlement demand.

The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from an attorney licensed in your state. Find a local attorney to give you a free case review here, or call (888) 647-2490.

Best of luck,

Judge Calisi

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Comments for Does insurance pay before the doctor visit?

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Hit in the head with a baseball
by: Anonymous

My 14 year old son was hit in the side of the head just behind the ear about 1 1/2 years ago at a pro baseball game (before the game). After everything settled down he ended up with a bruise and a baseball imprint in that spot. It healed and we ended up having a good day.

About a year ago the school gave the yearly hearing test and he failed parts of it and had to see a specialist where it was determined he has a low tone hearing loss.

The only thing we can come up with (us and the doctor) is a possible broken small bone in the ear and we're concerned it might get worse in the future. We don't know if too much time has past or if we have any legal options to cover possible future medical issues. Thanks for your time.

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