Is it my responsibility?

LindaS · September 2007

I have an EE whose underage son was in a serious car accident over the weekend after he had been at a party drinking alcohol. He does not have life threatening injuries but there will be extensive reconstructive surgery and rehab.

Our health insurance plan states, as do most, that injury or illness as a result of voluntary participation in illegal activities are not covered. Do I have a responsibility to inform her of this or do I wait for her to find out?

I'm thinking that I should say something to prompt her to hire an attorney to assist with the charges but do not want to overstep my bounds.

What are your thoughts?

ritaanz · September 2007

You cannot be sure how the doctors complete the necessary forms. Doctors know the ins and outs of the insurance companies rules and regs.

I suggest that you just watch.

ray a · September 2007

I usually do as Ritaanz suggests, but in some cases I have warned the ee that they might have problems.

NeedCoffee · September 2007

In cases like this, I would probably give the EE the phone number of our insurance broker - she assists employees in understanding the workings of their insurance plans when things become hairy, such as major surgery, claims negotiations, etc. That way, the problem is off my plate, and once the broker receives an authorization from the EE, HIPAA doesn't have to be worried about.

Irie · September 2007

I too would advise the employee that there may be some limitations to what the plan will cover and suggest she contact member services.

Since you don't process the claims (at least I don't think you do) you never know how the insurance company will handle this type of situation.

Msferra · September 2007

My question first would be how did you find out about the information? If through the grapevine or even if the employee told you herself, I think that you have a responsibility to inform the insurance company. She may say anything she needs to in order to get the bills paid. When asked what happened, she could just say that he was in a car accident and leave out a few details, if you know what I mean. Unless the insurance company does their due diligence, they may not find out and her son's bills will have been paid fraudulently and turn into a big mess that you might have to deal with later on. You are a client of the insurance company and as cold as it sounds, you are also trying to keep your premiums down by making sure that things that supposed to get paid for do, and fraudulent claims do not. I think that you should inform her of the plan document stipulations and make sure that she contacts the insurance company herself.

LindaS · September 2007

Thanks for the replies. I approached her and informed her that she would be getting alot of paperwork in the near future from the insurance company and to let me know if she had any questions. Because of the situation she became very defensive right away and I think she knows there may be some issues with payment of claims due to the son's drinking then driving because her comment to me was that she did not care what she had to do but that she would make sure things were taken care of for her son.

Irie · September 2007

Linda: If you have a broker you may want to run this by them to see what they think you should do. I know if I were in this situation I would contact my broker and let them know what is going on.

lrobb · September 2007

Was he driving? I would think that the Ins Co will want a copy of the accident report. If the investigating officer noted he was drinking there may well be issues. If the accident report fails to note if he was drinking then there may not be any issues unless it is noted on hospital records. Either way if he was drinking and no one noted it at all it will be difficult to deny a claim without corroberation from the ER or PD.

Pattie · September 2007

Your employee may have become defensive for any number of reasons -- just the fact her son was in a serious accident and faces a long recovery is enough.

The previous question is important - was he the one driving or was he a passenger? And just because there's an accident report doesn't mean charges are filed. The accident report and health records will determine a lot.

I think you need to tread lightly and discuss this with your broker. This is an area where HR is walking carefully on that "fence" in terms of duty to employer and trying to be helpful to the employee.

LindaS · September 2007

Yes, he was the driver (the only one in the car, thankfully) and the parents are awaiting the blood tests to determine level of intoxication. He admitted to drinking several beers before getting into the car so only time will tell. The police officers on the scence wrote two citations and the level of intoxication will determine which is processed.

I understand her becoming defensive and I don't blame her. I feel like I'm "riding the fence" in that I know she has alot on her mind and I know, from talking with the insurance company, that if the accident is determined to be a result of his drinking and driving, the health insurance company will not accept payment of any of the bills.

On the one hand I do not want to burden her with more than she can handle but on the other hand I feel like she should be prepared should the insurance company deny the claims (and they will be priceY!!).

I think at this point I am not going to say anything until she gets the test results back. Once she knows more then I will gauge whether or not to give her any additional information.

Pattie · September 2007

What may very well be her "saving grace" is that the Auto policy typically takes precedence in payment of any medical bills as a result of an auto accident, with any health insurance being secondary. She should be looking at her auto policy as a source of covering some, if not most, of these expenses depending on her level of coverage.

dbutton111 · September 2007

I agree Patti, the auto insurance should be primary in this case.

kdspa · October 2007

Pattie - I'm thinking the exact same thing. Her auto coverage will more than likely take precedence.

lrobb · September 2007

Additional thought. Since the driver was underage any alcohol consumption would be an act in violation of the law. He doesn't have to be intoxicated. In most insurance policies if you are violating the law at the time of the claim they won't pay. You may want to see if your policy has this excluision.

Is it my responsibility?

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