Personal Injury Treatment Coverage

Attorney List: Periodically I am asked for attorney referrals. I can not make a direct referral.

It is a good idea to write down your questions prior to scheuling a consultation with a personal injury attorney, whether you do it in person or by phone.  How they relate to you and answer your questions will aid you in ultimately making a decision to whom you ally yourself with. 

It is important to know your legal rights as an injured driver.  Most attorneys offer FREE consultations.  Being not informed regarding your legal rights and not knowledgeble in negotiating a settlement with the insuance company can work against you.

The Automibile: A Necessary Expense

A necessary expense in California for each of us purchase, maintenance and insuring an automobile.

Your body is a vehicle like your automobile. You purchase health insurance to cover any unexpected incident or illness that may occur. The same approach is applied to the insuring of an automobile.  There is one major difference in the two.  The automobile travels at great velocity.  This velocity is responsible for damage to other cars and the human body upon impact into another stationary object, such as a tree etc., or into another car or truck.

Injuries In Low Impact Automobile Accidents

Injuries can be minimal at a very low impact. However, they can alter ones health to the point where they need minimal medical, chiropractic or alternative care.  A majority of automobile accidents are of the rear end type hence they are considered low impact less than 45 miles per hour.  The fact that they are termed "Low Impact" does not mean that there is no amount of injury to the human body. Just the opposite occurs. The lower the speed the greater the chance of the force of the impact [inertia] to transferred into the passenger compartment. This creates a "whipping' motion of the head causing muscle as well as ligament tearing.  The result is soreness of the muscles of the neck and limited motion. Also the fact that we have safety mechanisms installed into the automobile helps against gross injuries of the head, face, chest, sternum, arms [namely broken bones] but the seat belt causes other injuries known as "seal belt injuries".  These areas of injury should be addressed immediately as they can create chronic sites of injury and pain patterns.

General Information Regarding Automobile Insurance

First I have to review with you a disclaimer. I am not an insurance agent nor am I representing an insurance company. My information is by way of experience over the last 30 years of practice.

There is a difference between an "insurance broker" and an "insurance company".   The insurance broker represents one or many insurance companies that may offer policies to individuals to cover their automobile.  The insurance broker represents you, the insured. The insurance company is a specific company that may have only one product or many products to sell to you.  In addition if there are any claims, the insurance company is responsible to pay, NOT the insurance broker.

There is a procedure to obtain insurance: First there is the application; Second, there is the "Binder". Third, there is the "Receipt"; And finally there are the payment plans either monthly, semi-annually or yearly.   The "Binder" is a certificate of insurance.  This item is necessary for the California driver to register the automobile.  This is usually in the name of the owner of the vehicle.    The "Receipt" is when the automobile owner pays a partial or whole part of the premium to the insurance broker or agent. 

Financial Responsibility

Many states have what is known as the "Financial Responsibility" Law that is designed to make sure that any motorist has enough insurance to cover for damages cause to other vehicles or persons.   There are also minimum requirements for insurance. You will have to contact an agent to find out what the current coverage minimums are.

Unfortunately, even with this law some individuals use the "obtained binder" of insurance coverage to register their auto, and then terminate the insurance.  They thereafter drive with no insurance…therefore being classified as uninsured. IT IS ILLEGAL IN THE STATE OF CALIFORNIA.

Types Of Automobile Insurance:

Property Damage        Property damage pays for property damaged due to a collision.  Such items are: crushed fender; broken glass; damage wall or fence.  This coverage is for the primary driver of the vehicle and another if granted permission by the primary driver or owner.

Bodily Injury                          This DOES NOT PROTECT YOU or YOUR CAR DIRECTLY. If you injury other people it protects you against their claims for medical expense, lost wages, pain and suffering and other losses. It will usually pay if the accident was caused by a member of your family living with you or a person using your auto with your consent.

Uninsured Motorist (UM)       This applies to injury to you, your family, and other occupants when hit by an uninsured motorist or a hit and run driver. It also covers you or your family if hit as a pedestrian by an uninsured motorist. It makes sure that the money is available if you are injured by someone else. It DOES NOT cover your property damage and does not protect the other driver.

Underinsured Motorist (UIM) This increases the bodily injury protection.  It becomes effective when the party causing an accident has lower bodily injury limits than your Underinsured Motorist limits.

Example:  IF the Underinsured Motorist insurance limits were $100,000 per person and the person causing the accident had limits of $50,000 per person. Under this scenario you could collect up to $50,000 from the at-fault driver and up to an additional $50,000 (the difference of the limits) under your own Underinsured Motorist insurance coverage.

NOTE:  Unfortunately, this is not as easy as it seems. Most of the time you will have to obtain an attorney to represent you. You will be filing suit against your own insurance company to obtain the difference.

Collision  This pays if your auto collides with an object, including another car, or if it overturns. It will pay even if it is your fault.

Comprehensive   This covers almost any other causes such as fire, vandalism, water, hail, glass breakage, wind, falling objects, civic commotion, or hitting an animal. It also will cover automobile parts, such as battery or tires if they are stolen.  Flood damage is also covered under this category.

Deductibles  Both Collision and Comprehensive have deductibles. These may vary. The insurance cannot tell you what to carry.  You have to determine how much you can afford if something occurs.

Medial Payments  This coverage is pays medical or funeral expenses for you or others injured or killed in an accident while riding or driving in your auto.  This includes all reasonable hospital, surgical, chiropractic, x-ray, dental, professional nursing, prosthetic, and rehabilitation expenses up to the limits of the coverage. Medical Payments insurance usually covers only those expenses not covered by health insurance, such as co-payments, deductibles, etc.

TYPE OF PRACTICE

 

Over the last 30 plus years my practice has treated a high percentage of personal injury cases, automobile accident injuries.   The practice is diversified where I not only treat the human spine but other regions of the body that may be injured in an accident.

 

SCENARIOS OF INSURANCE COVERAGE

 

KAISER INSURANCE COVERAGE:

 

Patient States -  "I have Kaiser Insurance and do not need automobile medical coverage [med-pay]! 

 

Answer: This is fair coverage if you are in the Kaiser Hospital region to receive emergency care.

 

Kaiser Insurance DOES NOT cover the following outside healthcare facilities:  Chiropractic, Specific evaluation or retraining of an individual due to an automobile accident.  They will not cover secondary evaluations. 

 

Patient:"Why should I pay for my care if I have Kaiser insurance? I am not going to pay out of my pocket for an outside consultation!"

 

Answer: When using the Kaiser system it is better to utilize an outside doctor to make a diagnosis of your condition and then present it to the Urgent Care Nurse at Kaiser for their records. You are more likely to expedite matters regarding your care.

 

Patient: I have chiropractic provisions on my Kaiser Insurance. Why should I go to you?

 

Answer: Some Kaiser plans have chiropractors on their provider list (I am not included on this list).  If you are covered and are in an automobile accident the chiropractor will get paid at a reduced rate and the insurance company will profit by billing the other insurance company getting paid the full reimbursement of what the doctor billed.  

 

This is not fair to the doctor or to you, as you will use up your chiropractic coverage, which is to be for general accidents, injuries or conditions other than an automobile accident.

 

 If you take the cost of the optional chiropractic coverage lets say $350 a year that amounts to approximately $29 per month.  You can see that not only are you loosing chiropractic coverage for the balance of a year after placing a claim through your general medical insurance for an automobile accident after your insurance is exhausted you are still paying for the health coverage on a monthly basis. Think again about that cost of medical coverage. Make sure that when you talk to your agent that you DO NOT get "Excess Medical Coverage or "Modified Medical Coverage.  An explanation of these two will follow.

 

 

EXCESS OR MODIFIED AUTOMOBILE MEDICAL COVERAGE

 

The following situations may occur with the following results:

 

  1. No private insurance -  In this case the Excess or Modified insurance will be billed as     the primary insurance coverage.

 

  1. Have Kaiser Health Insurance or other PPO or HMO [Private Health Insurance] - In this case your Private Health Insurance would be billed first, then the Excess Medical Insurance.

 

VARIATIONS OF EXCESS OR MODIFIED MEDICAL PAYMENT COVERAGE

 

Modified         80/20             

There will be a deductible and a co-payment of 20 percent of the  billing. The deductible amount may vary. Usually the higher the deductible the lower the insurance premium.

Private Health Insurance will be responsible for making the primary payment and the insurance will pay for the balance after the deductible has been met.

Note: There is other percentage co-payment Modified plans available by different insurance companies that are not represented here.

 

TYPICAL MEDICAL CHARAGES IN A MODERATE TO SEVER AUTO  ACCIDENT

 

Service Rendered                              Cost

Ambulance  1/4 mile                           $ 850 to     1,500

ER Room                                               300 to     1,000

X-rays one view                                     150 to        300

Admitted Overnight                            $  3500           

CT Scan                                              $  2400                                                     

MRI                                                       $ 1800 to   2,400 per area

 

Chiropractic Care                               $ 2300

Medical Care                                       1500

Consultation other providers                 600 to         800

Neurological Consultation                     600 to         800

 

            Total Average Cost               $ 14,000  to 16,500

 

The above typical cost for moderate to severe treatment for injuries from an automobile accident DOES NOT include: loss of limb, rehabilitation for injured limb or brain damage rehabilitation, diagnosis of disc herniation or operation. This can escalate the cost of treatment to up to $ 100,000 or more. 

 

PREMIUMS FOR STRAIGHT NON-MODIFIED MEDICAL PAYMENT

 

The premium for "Medical Payments" or "Med Pay" depends upon the following:

Driving record of the individual; Level of insurance coverage; Age and sex of the individual; and Type of car and how it is utilized.  The cost of the medical coverage is not regulated by the state of California. You will have to shop around for the best coverage. 

 

With a 97 Ford Explorer All Wheel Drive having $100,000/300,000 coverage with the individual having a good driving record the cost of FULL medical coverage would be the following: [This quote is with a high quality insurance company, others are lower]

 

            Coverage Limit                       Cost Per 6 months       Cost Per month

 

            100,000 Med Pay                    $ 54.90                        $ 9.15

              10,000 Med Pay                       32.00                           5.13

                5,000 Med Pay                        19.90                          3.33

 

I do not have the cost of $30,000 Medical Payments coverage but as you can see the cost is relatively inexpensive.

PRIVATE HEALTH INSURANCE COSTS PER MONTH

 

The cost of Private Health Insurance whether Kaiser Healthcare or PPO or HMO can range from $ 29 per individual [through large groups] to $ 149 per family per month. 

Now compare the cost of the insurance coverage cost of $ 29 per month to the cost of Medial payment.   Are you really saving money…or is your health costing you!

My advice to every patient is to not carry less than $30,000 medical payments coverage.  Automobile accidents can be expensive placing your body back in shape.  The following are typical medical charges on a moderate to severe type of automobile accident.

 

THE TRUTH ABOUT MODIFIED MED PAY:   That the insurance agent and company will not tell you.

 

If you have Private Health Insurance and HAVE to use this with the Modified Med Pay then the cost of your insurance goes way up! 

 

If the cost of your Private Health Insurance is $29 per month it cost you $ 29 x 12 or $348 per year.  This is for the cost of coverage for chiropractic care.

 

Let us say that you get in an automobile accident in March of the year. You have already paid 3 months premium for Private Health Insurance.  If your policy covers chiropractic care for injury, illness or accident, you will have to use this first then the Modified Med Pay. 

 

A majority of Private Health Insurance coverage for chiropractic care is limited. Let's say it is caped $1,500 for the year. You are still obligated to pay the $29 per month for this coverage for chiropractic care.  If you have 9 months remaining that is $ 29 x 9 or $ 261 remaining on the Private Health Insurance coverage. You will not get benefit from the insurance due to the fact in most accidents individuals bills are around $ 1,500 to $3,000, [which does not include any outside referral for diagnostic services.]

 

The cost of the Modified Medical Pay is less than the regular medical payments. Let's say that you got  $ 5,000 Modified Med Pay for $ 20 per year to keep your automobile insurance premium low.   This is where it gets interesting regarding your "savings".

 

Cost of Modified Medical Automobile Insurance                 $            20.00

Cost of Private Health Insurance                                            $          261.00

Total Cost for Insurance for an accident                                $          281.00

 

The cost per month for using up your chiropractic medical care that should have been utilized for other than an automobile accident i.e. falling off a bicycle, slipping in the back yard, moving the piano and throwing your back out, goofing around wrestling and throwing your back out… etc. now increases to $ 23.47 per month.

 

As you can see the cost differential of having the Modified Medical Payments coverage on your automobile has gone from $ 1.66 per month to a $ 23.47 per month.   It is ALWAYS cheaper to get the STRAIGHT NON-MODIFIED AUTOMOBILE INSURANCE.

 

THIRD PARTY CLAIMS

 

This usually occurs when someone is hit by another vehicle. You do not have medical payments provisions on the automobile. The owner of the vehicle also does not have medical provisions for themselves nor for the passengers.  In this case the hitting car will cover medical cost and will ONLY make payment at the termination of all injured persons. They have no binding contract agreement with any medical provider or chiropractor to pay them for services rendered.  In this case that person without insurance will have to do the following:

 

  1. Pay out of pocket for medical or chiropractic care. This office will charge a co-pay for each visit that the patient comes in for care in this type of persional injury claim.
  2. Have their private health care insurance cover the cost for medical or chiropractic care if applicable (Circumstances vary with insurance company)
  3. Obtain an attorney to represent them against the hitting party.  This is known as a "Third Party Personal Injury Claim".

 

It is the policy of this office in the majority of THIRD PARTY automobile accidents that the patients get an attorney. The reason for this is there is nothing guaranteeing payment for the medical bills. Having an attorney guarantees my interest in getting paid after the other insurance company makes settlement with all of the parties involved.   Unless otherwise agreed between the patient and the doctor this is the case.   Why?  When the insurance company settles without an attorney, they are obligated to make payment to the patient.  Many patients in the past have taken the monies as their own placing me in the position of being a "Collection Agent".  This creates bad will, frustration and reduces my payment from 50 percent to nothing if I cannot get any payment from the patient.

 

Note: At times there are liability issues that will have to be defended by an attorney.  It is not a good idea to try to settle your case with an insurance company.   You do not know the personal injury case law or the results of present case proceedings.  It is not good for an attorney or doctor to try to negotiate his own personal injury case…I strongly advise against itThe hitting parties insurance company will continue to contact you offering small settlement amounts for your injury, suffering and loss of time from either work or hobby.   They will sound friendly, but watch out.

 

CALIFORNIA LAW:

 

The clock is ticking on the "Statute" to file a claim against the other party. In California it is one year from the date of the accident up to the minute.

 

 

****WARNING****EXCESS MEDICAL COVERAGE****WARNING****

 

 

Some insurance carriers are taking advantage of the healthcare provider and their own insured.  The essence of this type of policy is that the medical pay insurer will only pay the uncovered or "Excess" medical bills after the primary health insurer has paid.

 

We are required to bill the patients' regular health insurance carrier first, then obtain and submit the written EOB to the auto medical insurer.  The prime reason for this type of policy is to limit the reimbursement to the healthcare professionals.   The "Excess" carriers limit reimbursement by how they arbitrarily choose to interpret the Explanation of Benefits (EOB) from the primary health insurance.

 

In the case of a managed care carrier (HMO/IPO) the deductions can be quite severe. In these cases the reimbursement for a given service is quite low, the number of visits authorized is below established norms, and the number of modalities/procedures and durable medical goods allowed are restricted. The "Excess" carriers in this type of setting salivate at how much they cut the billing.

 

TAKE CARE OF YOURSELF FIRST!!!!  NOT the insurance companies pockets.

 

 

I do hope that this has helped you to make a decision and call your insurance agent promptly to change your medial payments coverage.  DO NOT make him sway you into keeping the EXCESS or MODIFIED coverage.  YOU DO NOT WANT THESE.

 

Your health is a precious commodity. ONCE it is lost it is hard to get it back. A delay in proper treatment will be to your detriment. 

 

A famous San Francisco attorney, Melvin Beli said: "I don't care who the orthopedic specialist, neurologist, or medical doctor is, he cannot have seen and treated and helped as many patients as the Chiropractor within the chiropractor's field".

 

My advice to every patient is to not carry less than $30,000 medical payments coverage.  Automobile accidents can be expensive placing your body back in shape.  I urge you for you health and you family and anybody traveling with you that you contact your agent and GET THE NON MODIFIED WITH NO DEDUCTIBLE MEDICAL PAYMENTS added to your policy TODAY!

In closing I have to re-state that I am a chiropractor, not an insurance agent or an attorney. However, you can see that practice is involved in knowing certain circumstances of different cases. 

I do hope for your health sake that you do change your present automobile insurance coverage to your benefit.

I do hope that this information has been helpful.  If I can of any further help to you regarding the above, feel free to contact me.

Sincerely,

Dr. James R. Sabato, D.C.

 

 

Disclaimer:

 

Cost for insurance will vary from each insurance carrier. Do your shopping. These prices presented in this “A Necessary Expense – The Automobile” packet are estimates and may not be close to the cost associated with insurance at the time of your possession of these pages.