Traumatic Brain Injury - The Medical Insurance Maze
Even if you’re fortunate enough to have good medical insurance, the expenses associated with a traumatic brain injury can be overwhelming. While a mild brain injury can generate as much as $85,000 in medical costs, it’s estimated a severe traumatic brain injury can exceed $3 million in lifetime costs for treatment, rehabilitation, and ongoing care.
Your share of these costs depends largely on the provisions of your health insurance policy. Still, you can be saddled with personal responsibility for additional expenses by not being aware of your policy’s provisions and by not following claim procedures carefully.
Maximum Lifetime Benefit
Coverage for hospitalization expenses will usually not be an issue under most health insurance policies until the maximum lifetime benefit is reached. Not every policy includes this limitation, but for those that do, $1 million is a common maximum. However, terms can vary from a low of $500,000 to a high of $5 million. When the lifetime benefit limit is reached, you effectively have no further medical insurance coverage.
“Lifetime” refers to the life of the policy, not the individual insured. Deducting the value of benefits already received from the maximum tells you what is remaining, but it is probably quicker and easier to call your insurer or agent to find out.
Keep in mind that a severe traumatic brain injury can generate more than $1 million in medical bills in a matter of months. It’s best to know the limits of your policy as soon as possible so you can pursue other resources for covering medical expenses in a timely manner if needed. (See Paying for Medical Costs of a Brain Injury.)
Annual Maximum Benefit
As a means of reducing monthly premiums, some lower-cost policies may have an annual maximum benefit. When this limit is reached, the policy no longer covers medical expenses until the beginning of the next policy year. The policy year may start on the policy’s anniversary date, or it may be based on the calendar year.
You should know if your policy includes this limitation, and if so, when the next benefit year begins. Also, ask your agent or insurer if the date for resuming benefits is based on the date of service (when the medical procedure or service occurs) or based on the date of claim (usually filed some time after the service is actually provided.)
You will have practically no choice in timing critical care needs, but in the later stages of recovery, you may have flexibility in timing medically related services so they fall into the next policy year and are covered by your insurance.
Preferred Service Providers
Be aware if your policy pays reduced benefits for services obtained from out-of-network providers. The terms of coverage for out-of-network providers can vary significantly between different insurance policies, but may include higher deductibles, higher co-payments, and possible liability to the service providers for any portion of the bill not paid by insurance.
Policies usually allow for emergency treatment in any facility, but coverage may be reduced. It may be necessary to transfer care to preferred providers after the patient is stabilized. Though it’s painful to have to deal with such mundane issues during a crisis, you can probably find sympathetic help in figuring out your options from the hospital admissions department.
Also, if referrals and pre-authorization are required, be sure to take all those steps as soon as possible to avoid a denial of claim.
Read the rest of the article: 1 2
Comments
1 Comment so far
Thanks for participating in the second carnival of special needs and money.
Kim Greenblatt