After I Settle My Injury Case, Who Do I Have to Reimburse?

People that Will Try to Take Away Parts of Your Settlement   

After you settle or try a case to verdict, you may have to deal with a multitude of entities that will claim the right to be reimbursed for payments they made on your behalf. In addition to medical liens, which we previously discussed, if any of the following entities paid medical bills on your behalf, you may have to reimburse them.

Automobile Medical Payments Insurance Reimbursement

Most automobile medical payments policies have language included in the contract that says they are entitled to reimbursement for bills they paid if you receive a settlement for those same bills.  In Georgia though, there is a statute that protects consumers from having to reimburse these companies unless you settle your case for an amount that exceeds the total of all lost wages, medical bills and pain and suffering.  In practice, very few medical payments insurers are dumb enough to sue their own insureds to gamble that a court will rule that the case was settled for its full value.
Here is the statute:

O.C.G.A. §33-24-56.1
(a) As used in this Code section, the term:
(1) 'Benefit provider' means any insurer, health maintenance organization, health benefit plan, preferred provider organization, employee benefit plan, or other entity which provides for payment or reimbursement of health care expenses, health care services, disability payments, lost wage payments, or any other benefits under a policy of insurance or contract with an individual or group.

(2) 'Injured party' means a person who alleges that he or she has been injured by the acts or omissions of a third party and who has received benefits from a benefit provider. This term also includes the personal representative of the estate of such person.
(b) In the event of recovery for personal injury from a third party by or on behalf of a person for whom any benefit provider has paid medical expenses or disability benefits, the benefit provider for the person injured may require reimbursement from the injured party of benefits it has paid on account of the injury, up to the amount allocated to those categories of damages in the settlement documents or judgment, if:
(1) The amount of the recovery exceeds the sum of all economic and noneconomic losses incurred as a result of the injury, exclusive of losses for which reimbursement may be sought under this Code section; and
(2) The amount of the reimbursement claim is reduced by the pro rata amount of the attorney´s fees and expenses of litigation incurred by the injured party in bringing the claim.
(c) In the settlement of any claim for personal injury, under circumstances where it is claimed that the amount of the recovery does not exceed the sum of all economic and noneconomic losses incurred as a result of the injury, a benefit provider which has paid benefits to or on behalf of the injured person may seek a declaratory judgment pursuant to Code Section 9-4-2 as to what extent it may equitably share in said settlement. If the court determines said settlement does not fully and completely compensate the injured party, the benefit provider has no right of reimbursement.

Medicare

Medicare is a government funded program that provides health benefits. By law, it is a “secondary payor” which means it does not pay out until all other sources of money, including the at fault driver’s car insurance has paid out. Sometimes they will pay ahead of time and the payment will entitle the program to a lien against the proceeds of any settlement.   
If Medicare pays out for medical care and you then receive a settlement or verdict for that medical care, they are entitled to be paid back. They will reduce the amount of their claim if you apply based on the following formula:
1)    Determine the ration of the procurement costs to total amount of the liability insurance payment, judgment or settlement payment;
2)    Apply this ratio to the Medicare payment. The product is the Medicare share of the procurement costs.
3)    Subtract the Medicare share procurement costs determined in step 2 from the lesser or the total conditional payments or the provider’s charges. The remainder is the amount to be refunded to the Medicare program.
Understand that the process is complex and you should consult a lawyer. In 2010, there will be drastic changes to an injured person’s obligations to Medicare if they will have future medical care to be paid by Medicare.

Medicaid

If your medical bills were paid by this program, you must repay the benefits according a specific percentage of the benefits paid. If you are dealing with a Medicaid repayment issue, you should consult a lawyer.

Health Insurance

Health Insurance companies will almost universally claim a right to be reimbursed from your settlement proceeds for medical care they paid for. The analysis of whether your health insurance is entitled to reimbursement is complex and turns on the analysis of whether the plan is governed by Federal law or Georgia law. If Georgia law applies, then the plan is only entitled to reimbursement under O.C.G.A. §33-24-56.1 if you have been “made whole.” If the plan is controlled by Federal law, then the state law is pre-empted and you need to negotiate with the health insurer. Some will reduce their liens by as much as 50% if a lawyer is involved.

Determining whether Georgia law or Federal law applies is a complex analysis and you should always consult a lawyer if you are dealing with these issues.

Workers Compensation

If worker’s compensation paid for the medical care that underlies the personal injury claim that you are making, they will assert that they need to be repaid and under Georgia law they can take several steps including filing suit or joining a lawsuit you already brought. Workers compensation companies are not entitled to be paid back from your case proceeds unless “the injured employee has been fully and completely compensated.” O.C.G.A. §34-9-11.1. If you are dealing with a workers compensation lien, you will need to get a lawyer involved. 

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