Pickelsimer LLC
Atlanta Georgia Personal Injury and Small Business Attorney

Atlanta Georgia Personal Injury Blog

Personal Injury FAQs and Legal News in Georgia

Do I have to payback my health insurance for payments related to an automobile accident?

My Health Insurance paid my medical bills after an accident. Do I have to pay them back?

As we lawyers like to say: “It depends.” You first need to investigate and understand what type of health insurance you have before any reimbursement or subrogation questions can be addressed.

Generally, private health insurance (compared to government plans like PeachCare, Medicare, Medicaid, Tricare, etc.) falls into two categories when it comes to reimbursement claims, sometimes also referred to as subrogation.

First, you have health insurance paid by premiums. This could be a group insurance plan you get at work or one you purchase yourself in the marketplace.

The second category includes employer self-funded plans governed by a federal law called ERISA. These plans differ from “regular” insurance in that you and your employer are not paying a premium for a risk of potentially requiring medical care, but instead you are paying into a separate fund. The contributions by you, your employer, and your co-workers are then pooled and used to pay for your and your co-workers' medical care out of the fund.

On the other hand, true health insurance policies require payment of premiums taken in by a health insurance company who promise to pay for medical care in the event you need it. Fully self-funded ERISA employer plans are more common among larger employers with greater assets, but smaller companies can do so as well. Adding to the confusion is that most self-funded ERISA plans will still pay a company like UnitedHealthcare, Aetna, or BlueCross BlueShield to "administer" the plan. This can make a self-funded plan appear to be a simple health insurance policy when in fact it is fully self-funded. The only real way to tell the difference is to acquire the Form 5500, Plan Documents, and read the language.

When it come to reimbursement, proper identification of these plans/policies is crucial. Under Georgia law the extent to which the health plan can be paid back depends on it. Fully self-funded ERISA plans require reimbursement of most, if not all, of the funds paid on your behalf subject to some exceptions that depend on the plan language. On the other hand, Georgia law puts the onus on non-fully self-funded health insurers to prove that your financial recovery, in settlement or verdict, “made you whole” or you were fully and completely compensated for all your damages. This is a high burden for the health insurer to prove in most cases, providing you leverage to pay back little if any of the benefits paid on your behalf.

Contact us today if you have been involved in an accident and are seeking legal representation after being injured in an accident.


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