wis-injury.com is your source for information on personal injury, liability, insurance and compensation. There has been a traumatic event, usually an accident, medical bills are mounting, you or your loved one are no longer the same as they were before. Is there compensation available?

If your loved one is in a coma, at least in the United States, they will not be denied care, at least not until the acute stage is over. While that doesn't mean you won't have financial hardship ahead, at this point, care will continue, regardless of how the bills get paid. At least in the United States, people with severe brain injuries are not denied acute care. In fact, the people who set hospital and insurance rates understand that and all of the rest of us pay a little more, on the chance that this kind of care is needed for someone who doesn't have the ability to pay.

If you are getting hassled about medical bills while someone is still in a coma, basically tell them not to bother you, that you have more important things to worry about.

Now that having been said, getting medical bills paid may become a priority. If the person is in a coma has a family or spouse to support, then finding a source to pay these bills will help to reduce the financial hardship caused.

While there will typically be deductibles associated with this policy, after the deductible, $250 to $1000, and the copay (20% up to $5,000 typically) they should cover all acute care costs. Unfortunately, with the advent of HMO's and managed care, getting the proper care from your medical insurance company may require you to be an "advocate." The term advocate is used to mean you may have to push them, argue with them, persuade, cajole and perhaps threaten them. While every insurance policy is different, the medical insurance companies obligation to pay for necessary care is much broader than they will typically admit to.

One suggestion from an insurance professional, who is now a caregiver, is to try to get a case manager appointed. A case manager has the authority to make decisions that make sense both for the patient, and also to lessen the long term burden on the insurance company. For example, providing some in-home care, may not be authorized by the policy, but may be much cheaper than the alternative of a nursing home, which is covered.

"I am a speech pathologist who works with TBI. I have worked in a variety of settings over the past 13 yrs, and have seen the HMO's take over healthcare. Don't ever be deceived into thinking your doctor can determine the course of your loved one's medical care. It is in the hands of the insurance company. Some of these insurance networks are set up so that the doctor is given X amount of dollars each month for each patient. If that person stays well and doesn't see the doctor, the doctor pockets that money. If the person has to come in for a visit, and tests need to be run, the doctor loses that money. Of course, there are many ethical docs out there but they are being squeezed by the system. I do post-acute care with most mild brain injuries. I can't even get funding from most HMO's or private insurance companies, thus most of my practice is made up of worker's compensation. And don't think the providers are getting rich, either. When I call a private insurance company to find out about a new patient's benefits, I am usually told that they will pay 70 or 80% of the "usual and customary rate". They won't tell me what that rate is. And legally I am not allowed to call other speech pathologists in town and find out what they charge because that would be considered collusion or price fixing. So every patient I treat with private insurance is a gamble for me. I don't get paid until 2 or 3 months after I provide the treatment and I have no idea how much I will be reimbursed. Crazy way to try to make a living, huh? But I love my work. I have met so many wonderful people over the years from every walk of life. This may help some of you to get your loved one into a rehab program if you have private insurance or an HMO: You can ask the insurance company to assign a case manager to your loved one's case. That gets you out of the narrow confines of the policy, because a case manager can trade benefits around. What I mean is, if there is a benefit in your policy that it is likely will never be needed, they can use the dollars from that portion of the policy to pay for something like a rehab program that is otherwise not expressly covered by the policy. A claims adjuster can't do that. Ask that your loved one's case be moved into case management. Not all insurance companies will do this." - Holly

If the survivor was injured in an accident, there is a significant probability that what we will refer to as "Med Pay Coverage", is also available. Med Pay coverage is additional insurance to cover medical bills related to the accident. Such a policy may be on the car that the survivor was riding in, any other car owned by the survivor or a member of his or her household, or on the place where the person was injured, such as in a fall. In some states, where there is no-fault or personal injury protection laws ("PIP") the Med Pay coverage may pay all the bills, but this differs from state to state.

It is a good idea to have an attorney review all insurance policies held by any member of the injured person's household, including umbrella policies, disability policies, homeowner's and even all policies on credit cards owned by the person. It may be that medical pay coverage is included in such policies.

With children, not covered by insurance, and adults who do not have substantial assets, medical assistance may be available. Medical assistance is available to someone who qualifies for SSI benefits from the social security administration. SSI, as opposed to SSDI, is available to people who do not have a substantial work history (have not paid in social security taxes in enough quarters) but who need assistance because their income and resources are below the minimum level. To understand more about qualifying for social security, go to the social security page herein.

If the survivor is eligible, medical assistance should pay all acute care costs, and substantial amounts toward long term care and rehabilitation. Medical assistance waivers, which are becoming more widely available, can sometimes be utilized to get medical assistance to cover things not typically covered by the program.

In most states, if the injury occurred at work, workers compensation is obligated to pay all related medical bills, especially for acute care costs. But as workers comp benefits are being trimmed to make states more competitive to recruit industry, an attorney may be required to force the insurance company pay all that is necessary for long term care and rehabilitation.

One final way to get medical bills paid is through a lawsuit, against someone who is legally responsible for the injury. And if you have a viable action, the survivor may recover many times the medical bills in lost wages as well. To recover in a personal injury action, the survivor must prove that someone else wrongfully caused the injury.

If an insurance adjuster is there early in the process, seemingly generously offering to pay all medical bills, don't sign anything. When faced with the pressure of catastrophic medical bills, the promise to pay all the bills may sound wonderful. Regardless of how much they try to endear themselves to you, the insurance adjuster is not your friend. He is not offering to pay medical bills out of the goodness of his heart, but to avoid paying substantially more. The insurance adjuster's job is to pay as little as he can. An early offer to pay bills is tantamount to an admission that they realize they are responsible to pay far more.

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