Health Plan Reimbursement Claims After an Injury

If you were hurt and your health insurance paid for your treatment, you may later get a letter from the plan, or from a company working for it, asking to be repaid from your injury settlement. Many people are surprised by this. They paid their premiums, so why should the plan get money back? The answer usually lies in the plan's terms and the law that governs it. This guide explains the general idea of health plan reimbursement claims and what to ask before your case settles.

What a reimbursement claim is

A reimbursement claim is a request by a health plan to be repaid for medical costs it covered when someone else may be responsible for your injury. The idea is that the plan should not end up paying for care that the at-fault party's insurance later paid for through your settlement.

You may also see the word "subrogation." In general, subrogation refers to the plan's right to step into your shoes and pursue the responsible party. Reimbursement refers to the plan's right to be paid back from what you recover. Letters often use both terms, and the difference can matter. Ask your lawyer which one is being claimed.

Reimbursement claims are different from medical liens filed by providers. A provider lien is usually about an unpaid bill. A reimbursement claim is about money the plan already paid.

Where the right to reimbursement comes from

Whether a plan can seek repayment, and how much, depends mostly on two things:

• The plan documents. Many plans include a section on reimbursement or subrogation. The exact wording matters a great deal.
• The law that applies to the plan. Different laws can apply depending on the type of plan, such as an employer plan, an individual policy, or a government program. Some state laws limit reimbursement for certain plans; other plans may not be subject to those state limits.

Because the type of plan can change the rules, one of the first steps is to find out exactly what kind of coverage you have. Your plan's member services line or your employer's benefits office can usually tell you. The USAGov health insurance page gives an overview of coverage types, including employer plans, Marketplace plans, and public programs.

Government programs

If Medicare or Medicaid paid for your injury care, they may have repayment rights as well, and those rights follow their own rules. These claims often must be resolved before settlement money is paid out. The USAGov Medicare page and USAGov Medicaid and CHIP page are places to start finding official contact information. Your lawyer can explain how these claims fit into your case.

How reimbursement claims affect your settlement

When your case settles, your lawyer typically:

1. Asks the plan for a list of the payments it made for the injury
2. Checks that each payment is related to the injury, not to other care
3. Reviews the plan documents and the law that applies
4. Asks whether the claim can be reduced, if there is a basis to ask
5. Pays the agreed amount from the settlement or holds funds until it is resolved

Errors happen. A plan's list may include treatment that had nothing to do with the accident. Reviewing the list line by line can matter.

Whether a claim can be reduced depends on the plan language, the law that applies, and the facts, such as how large the settlement is compared with the total losses. Some plans have firm repayment rights. Others may agree to reduce their claim. No lawyer can promise a reduction.

What you can do early

You can make the process smoother by starting early:

• Tell your lawyer what coverage you have, including employer plans, individual plans, Medicare, Medicaid, and any secondary coverage.
• Keep every letter from your plan or any company asking about your accident.
• Answer accident questionnaires carefully. Plans often send forms asking whether an injury was caused by someone else. Share them with your lawyer.
• Save explanation of benefits forms, which show what the plan paid.
• Ask for the plan documents if you do not have them, especially the section on reimbursement.

Questions to ask a lawyer

When you meet a lawyer, consider asking:

1. What type of health plan do I have, and which rules apply to it?
2. Does my plan have a reimbursement or subrogation clause?
3. Is Medicare or Medicaid involved, and how will that be handled?
4. Will you review the plan's payment list for unrelated charges?
5. Is there a basis to ask for a reduction?
6. How will this affect the timing of my payment?
7. How does your fee work if you negotiate the claim?

Our personal injury practice page lists lawyers who handle injury claims and settlements. You can read related topics in our legal guides.

If you need help paying for care

If you still have medical bills or need coverage after an injury, the USAGov health insurance page explains options. If cost is a barrier to getting legal help, the USAGov legal aid page lists programs that offer free legal advice and help finding free or low-cost attorneys.

Frequently asked questions

Why does my health plan want money from my settlement?

Many plans include terms that allow them to be repaid when another party is responsible for an injury the plan paid for. Whether your plan can do this depends on its documents and the law that applies.

Is subrogation the same as reimbursement?

They are related but not identical. Subrogation is generally the plan's right to pursue the responsible party; reimbursement is its right to be repaid from your recovery.

Can the plan claim more than it paid?

Generally a reimbursement claim is tied to what the plan paid for injury-related care. Ask your lawyer to check the amount and the plan terms.

Should I talk to my health plan myself?

You can, but it is usually wise to let your lawyer know first and share any letters, so that what you say and sign fits with your claim.

This page is general information, not legal advice. Laws change and every case is different — talk to a licensed attorney about your situation.