Etiquette of homeowners insurance and accidents
August 13, 2013 11:40 AM   Subscribe

My friend Stan (very) recently moved to the USA, and has already had a run-in with his health insurance that we are not sure how to deal with. Stan's new boss Joe invited Stan's family over for an afternoon, and at some point Stan's five year old fell and cut his arm on a rock in the garden.

After leaving Joe's place, Stan realised it was actually quite a nasty cut, and took the kid to an emergency room where it got glued together. Stan has insurance for his family through work, so they assumed it would be covered. However on receiving the claim, the insurance company has told Stan to claim it against Joe's homeowners insurance. Stan is very reluctant to go to his new boss and say "hey, I need you to pay for this medical treatment you didn't even know was required."

Is this something normal, and Joe will be completely unphased by the request? Or (best case) is it likely that Stan can refuse to claim through Joe and get his health insurance to pay anyway? If it comes down to it, Stan would rather just wear the cost himself than make his new job awkward - it's more money than he'd like to spend, but not enough to risk his relationship with his boss.

(Everyone is in Seattle, if it matters. I don't know the insurance company involved but could find out if necessary)
posted by jacalata to Human Relations (9 answers total) 1 user marked this as a favorite
His health insurance should cover the emergency room visit (to the extent that the policy covers emergency room visits). Homeowner's insurance shouldn't enter into it at all.

Like, I get that it's a thing that could be done, and that some people would do, but if I tripped and fell at a friend's house and busted up my arm, I wouldn't go asking my friend to hit up their rental insurance company to pay for it, you know?

What should happen is this: Stan goes to the emergency room and gives the emergency room his health insurance info. Emergency room should send Stan a bill with a notation that says something like "pending insurance approval." Hospital should bill the amount to Stan's health insurance company. Health insurance company should send Stan a bill itemizing the costs and coverage. Emergency room should re-issue a bill for the total amount less insurance, the out of pocket amount Stan actually has to pay.

If the insurance company is balking, Stan should say, "this item should be covered as per [such and such] outlined under emergency services in my explanation of benefits." (If Stan doesn't have his EOB he should get one from his employer/the insurance company.)
posted by phunniemee at 11:47 AM on August 13, 2013 [3 favorites]

I think phunniemee's answer is a bit of a misnomer. The question isn't about Stan's health insurance not covering the emergency room visit, it's that Stan's health insurance wants to subrogate the cost of the emergency room visit to the responsible party, which Stan's health insurance views as Joe. This is not uncommon; for instance, in not-at-fault car accidents, the medical care is paid for by the at-fault party, regardless of whether the not-at-fault party has health insurance or not.

Health insurance agreements uniformly require the covered party (Stan) to cooperate with the health insurance company to pursue subrogation when the insurance company views it as necessary. This is actually a good thing, as it keeps costs down. Although it is certainly awkward, if Stan doesn't cooperate with the health insurance company, he risks losing his health insurance coverage. Since the health insurance coverage is (probably) paid for by Stan's employer, Stan could consider taking this issue to HR, which would be a reasonable course of action.

Is this something normal, and Joe will be completely unphased by the request?

Subrogation is normal, but Joe will probably be a bit taken aback by the request. However, this is not an abnormal request, so Joe should not view Stan negatively for it.

Or (best case) is it likely that Stan can refuse to claim through Joe and get his health insurance to pay anyway?

No, that won't happen. The insurance company has the right of subrogation, and they won't give up on it just because you want them to. From their perspective, they are paying for coverage that they never correspondingly received premiums for, since the premiums assumed subrogation would happen.

If it comes down to it, Stan would rather just wear the cost himself than make his new job awkward - it's more money than he'd like to spend, but not enough to risk his relationship with his boss.

That seems like a bad thing to preemptively do; the emergency room care is probably more cost than you imagine. You could at least raise the issue of subrogation with Joe and see how he reacts.
posted by saeculorum at 11:57 AM on August 13, 2013 [11 favorites]

It's pretty customary for health insurance plans to expect you to obtain payment from any other responsible party, including other insurance. If you read your own certificate of coverage something to this effect will probably be in there. For example, the Washington state employee Uniform Medical Plan Classic Certificate of Coverage for 2013 says:
Here are some examples of common services and conditions that are not covered… These examples are called exclusions, meaning these services are not covered, even if medically necessary.

59. Services covered by other insurance, including but not limited to motor vehicle, homeowner’s, renter’s…
Once you have exhausted benefits (for example, reached the maximum medical expenses amount of the other insurance policy(ies), or services are no longer injury-related, the plan will cover services according to this certificate of coverage. [sic]
The homeowner's insurance might not have a responsibility to pay in this situation, though. It's more likely that the medical insurance company just wants to try to get anyone else to pay at all.

As to the social aspects of this, Joe may be totally unaware of this situation unless he has been through it or pays very close attention, so he may not exactly be unfazed by the situation. But he should know how much an ER visit costs in the U.S. and if Stan tells him that the medical insurance won't pay unless he contacts homeowner's insurance first, any reasonable boss would not hold it against Joe.

Also, the "explanation of benefits" does not explain what benefits you are entitled to. It is the explanation of benefits that you have already received. You want the "certificate of coverage."
posted by grouse at 12:01 PM on August 13, 2013 [3 favorites]

I'm surprised the health insurance carrier "told" the guy to submit a claim against the boss's homeowner's insurance and didn't just do it itself - i.e. Stan might not have a choice and the health insurance subrogation rules might dictate what happens. There is likely a set of subrogation clauses that specify that if an injury is due to a car accident, a work-related accident, or an accident in someone else's home, the other party's insurance might, in fact, be liable for the claim.

I was in the ER recently and my insurance company called me to make sure my injury was not caused by someone else whose insurance they could go after (and they definitely would not have left it up to me).
posted by Pax at 12:01 PM on August 13, 2013

Also, depending on the terms under which Stan is working in the US this may not be a standard health insurance policy but something that comes as part of a relocation package with different terms attached to it. He needs to read his policy.
posted by koahiatamadl at 12:02 PM on August 13, 2013

Also, if they pay out benefits subsequent to this incident, the plan may also have the right to sue Joe or his insurance company. I'm pretty sure that would make things way more awkward than an insurance claim.
posted by grouse at 12:05 PM on August 13, 2013

From a tactical perspective, Stan could probably approach Joe with, 'This is a weird thing my health insurance is requesting regarding the ER coverage for Stan Jr's accident. Is this a normal US-thing with health insurance?' Then he can gauge Joe's reaction.

If Joe seems outraged, that outrage should be directed at the health insurance company at that point, so he can thank Joe for telling him it's not normal (even if it is) and that he'll deal with it and then deal with it by paying for the visit himself.
posted by jacquilynne at 12:34 PM on August 13, 2013 [6 favorites]

Yeah, I think the best thing is for Stan to tell Joe "hey, strange thing -- I wound up taking Stan Jr to the ER for the cut, and now the insurance company told me they're going to be making a claim on your homeowner's insurance. I never realized that was a thing that happens here -- it was never my intention to bring you into this at all." (Not that Stan has done anything wrong, and not that he should have done anything differently -- it would have been a very bad idea to lie about where the accident occurred -- but some people don't understand how insurance works, and just in case Joe is one of those people, this should hopefully minimize the awkwardness.)

Stan should not offer to withdraw the insurance claim. The potential downside for him is bigger than the upside for Joe.
posted by fingersandtoes at 1:13 PM on August 13, 2013 [7 favorites]

Just an anecdote, which may or may not help:

Friend's wife was playing softball and while swinging the bat, accidentally hit another friend's kid in the jaw, enough to cause some injury. Friend and wife had other friend make a claim against their homeowner's insurance because wife inflicted the injury. Don't remember the particulars of where it occurred, but it probably happened at their house.
posted by tafetta, darling! at 1:14 PM on August 13, 2013

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