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After 3 years on workman's comp, I was approved for back surgery. Well, after surgery, I didn't come out of anesthesia. After a week, it was discovered that I had a brain tumor that was affecting my ability to come out of anesthesia.
Well, after brain surgery and a few months of rehab, things look in the clear. Well, my hospital gets a call from workman's comp, saying that they won't cover the bill of my brain surgery and subsequent hospital stay. The bills amount to over $200,000. I am barely getting by on workman's comp, and now they are putting a $200K medical bill on me.
I have been dealing with workers comp for two years in the state of virginia. Workers comp will not and do not have to pay for your brain surgery. This is why, The brain tumor is a existing illness un related to your work injury to your back. they will have to pay for the back surgery and then they will have to decide how much of the time in the hospital was needed to recover from back surgery. The brain surgery and hospital stay from it will not be covered. It is not related to the accident at work. Workers comp is only responsible for your work injury, mileage to and from appointments, bills from that injury, and medicine. They also have to pay a percentage of your salary. Depending on what state you live in you may be intitled to pain and suffering but that will come at the end of your case if you are entitled to it. they are in no way responsible for brain surgery bills, plus it does not sound like the tumor can be linked in an way to work. It just had not been found until your surgery. I hate to hear of your situation, I know that workers comp. is a pain. I had to get a lawyer, I have had two surgeries and now have permanent restrictions and have not got back to work. They can be something, but in this case I hate to tell you that they are not going to pay. i am not a lawyer and i do not know what state you live in ( every state has different work comp. guidelines) but workers comp is for work related accidents or illness. You may want to check with a lawyer to make sure you are getting everything you are entitled to as far as mileage reimbursement and medicine. Hope this help and please remember this is just my opinion based on what I have learned over the two years of dealing with workers comp. and the guide lines in Virginia.
Did they have you sign anything acknowledging that you were responsible for the brain surgery cost or did they assume it was covered by the same workmens comp coverage that took care of your back surgery costs?
I think they are supposed to verify that there is coverage before doing surgery, especially for something that is going to cost $ 200,000. I think they screwed up and are trying to pawn it off on you.
I had a problem on a much smaller scale. I had full insurance coverage but the hospital sent me a bill for about $ 7,000. I wrote letters everytime they sent me a bill and i eventually started telling them that if they had a document whereby I had acknowledged that I had to pay over and above my insurance coverage, I would pay it. I was gambling because who knows what they sign on the way to the OR? I still got nothing but bills cranked out by the computer, After almost a year a lady called me from hosp and said you know you have an outstanding bill to take care of. Isaid yes and I've written 10 letters telling you why I dont owe the $ 7,000. She said I havent seen any letters. Let me check and call you back. The next day she called and said you owe $ 50. I said send me a bill as fast as you can.
Well what does the brain tumor have to do with the workers comp injury, did the injury you have at work, cause the brain tumor ??? I doubt it, so your regular health insurnace should be paying for the bills from the brain surgary.
Only if the tumor was caused by the injury at work, would workers comp cover it. with that said, even if they cover it, it may take years of law suits, my last workers comp law suit took almost 10 years to settle and they settled in the court room before the case started.
Also do you have other health insurnace to send the bill to??
If it was me, I'd be as happy as a clam... You GOT your life saving surgery. All you're arguing over is the money. How would you feel if they refused to pay BEFORE your surgery???? Oh, that's right - you wouldn't be feeling anything.
Look, if you got nothing, then $200,000 is nothing but a number written on a piece of paper. It has NOTHING to do with your real life. You can't pay it, and they're not gonna sue you for it.
Frankly, in this great country of ours, lots of people are going without necessary medical care. You just got a FREE $200,000 operation that saved your life... I don't think that's too bad.
The brain tumor has nothing to do with the workmens comp claim. But if workmens comp denied the claim, I assume the hospital sent it to them, erroneously. So there is a good possibility the hospital assumed it was same as previous surgery and never checked into how a major $ 200,000 surgery was going to be paid for. I dont believe they take any chances wih those types of costs. I have never had any major surgery but I have always received written pre-authorization and I never contacted the insurance company, the Drs. or hospital did. I always ask the Dr. and/or hospital and they always say they have taken care of any prior approvals. If they persist you definitely need a good lawyer but they dont come cheap and there is nothing coming he can take a % of. Maybe he can get his fee out of the hospital if they made the error. Best of Luck to you.
I was thinking, your regular insurance should have to pick up the bill, and I am sure the hospital had to get pre-approval from somewhere. You did get the surgery you needed and now just have to dispute the bill. You usually can make payment arrangments through the hospital and you should be able to qualify for something like charity care that most hospitals offer to help with medical bills. This coould be checked in to through the hospital social service department probably if not they could tell you how to go about it. If nothing works out the hospital could get a judgement and try and garnish your wages, but until you are back to work, they can not touch your workers comp. because it is actually a state benefit and can not be garnished at least not in virginia. I would check into all this and I hope this helps. Remember just my thoughts.
Of course, all we know about you, is that you're on Workman's comp. You COULD be a very wealthy person on Workman's comp, or your could be a poor schlep just getting by on those checks..... My assumption was, (and it WAS an assumption) that you're down there at the bottom.
Ordinarily, that ain't a good place to be... However, when you've got a $200,000 bill, it's an EXCELLENT place to be. You're judgment proof. There's nothing to get EVEN if they did win. In order to win, they're going to need to hire an expensive lawyer. Hospital administrators aren't dumb. Hiring an expensive lawyer and going after YOU is throwing good money after bad. They KNOW this. I'm sure they are VERY familiar with your economic standing.
So, when I say they aren't going to sue you, I'm not just guessing. You aren't going to need a lawyer. You aren't going to need to go to court. When I said it has nothing to do with your real life, I MEANT that too. I'd put the bill on the refrigerator door and laugh at it every time I passed by.
excon
PS> IF your economic status is OTHER than what I assumed it to be, then the story is different --- but not much. Unless you're VERY wealthy, they know that even if they sue, they'll never collect what they're owed by garnishing wages.... Nope. I'd relax even then.
I am new here and I know from reading quite a few posts that there is a bit of a pecking order here. I am not trying to offend anyone, I just want to add a little to this conversation.
1. There aren't any hospitals that I have worked with are going to sneeze at an outstanding debt of that size. (if they did that for everyone they would never survive) They will take action. they probably would not sue you they would sell your file to a collection agency to handle. the collection agency will hound you for payment and if not received the bill will actually go into collection status. At that point they can if they choose obtain a judgement to garnish wages etc.
2. They may not be able to touch your workers comp benefits however that doesn't mean they can not go after any other assests. Also there is a specified time frame that they have to collect that debt. You may want to double check what the time frame limitations are because if you are back at work etc they can still come back and pursue the debt if it is still within the allowable time frame.
3. the hospital made an error by submitting the claim for the brain surgery to workmans comp. they need to resubmit to your regular carrier (as stated by numerous other posters) It is possible to obtain a retro active pre auth depending on the circumstances. I would check with you regular insurance company. And with that type of surgery and the high dollar amount you should also be assigned a case worker to help you out.
Hopefully I didn't offend anyone. Just learned from experience in the insurance field a few little tidbits
ps. from the sounds of it this surgery was a while ago. insurance companies all have a proof of loss clause which states that after a certain amount of time has passed since the date of service they are under no obligation to pay a dime. A lot of companies have it set at 15 months. Just an FYI
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