Visitor Question

What are CA laws related to medical insurance reimbursement?

Submitted By: Rebecca (San Francisco)

I recently received my first settlement offer from a claims adjuster for a slip-and-fall accident that I was in (I fell, resulting in a broken wrist and surgery). In the offer letter, the adjuster mentioned that my insurance can seek reimbursement for medical expenses.

I am very confused about how much they can seek reimbursement for, as this will impact my counteroffer (i.e. how much of the settlement will actually go to me and how much will go back to them).

I also am unclear what the particular laws are in CA related to health plans seeking such reimbursement. I have United Healthcare, a PPO plan.

Should I call the insurance and ask them directly about this, or would that just draw their attention to fact that they should seek reimbursement? Any help is greatly appreciated. Thanks.

Disclaimer: Our response is not formal legal advice and does not create an attorney-client relationship. It is generic legal information based on the very limited information provided. Do not rely upon the information in our response, or anywhere else on this site, when deciding the proper course of a legal matter. Always get a personalized case review from a localĀ attorney.

Answer

Dear Rebecca,

Call United Health Care and ask if you will have to reimburse them from your settlement with the third party insurance company (representing the company where you were injured in your slip and fall).

If, after you were injured, you turned to United Health Care to pay for your medical or chiropractic bills, out-of-pocket expenses, and lost wages, you will likely have to reimburse them for the amount they paid from your settlement (given to you by the insurance company representing the company where you slipped and fell).

You can review your policy with United Health Care. It’s likely you will find in it an “Indemnification Clause.” That clause states you, as the insured, are required to reimburse them for monies paid to you from a third party insurance company.

Whether you call United Health Care or not, know they will find out about any settlement funds you receive from the third party insurance company.

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

Best of luck,

Published: October 18, 2014

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