How do I determine how much I am entitled to for my medical treatment?

Paid Amount vs. Billed Amount

You are entitled to being compensated for any “paid” medical bills that were related to your injury caused by the at-fault party. This includes co-pays and any other out-of-pocket expenses related to your medical treatment, e.g., crutches, prescription medications, splints, etc.  This dollar amount differs from the “billed” amount, which you are not entitled to under California law.

All health insurance providers have contractual agreements with medical service providers, where they agree to not charge a patient the full-billed amount on certain procedures.  This is called a “contractual adjustment” and is not calculated into your personal injury claim.

Outstanding Amount

Any medical bills that have not been adjusted and show up as an outstanding balance that you owe are included in your personal injury claim.  You should note that it is important that you pay these outstanding bills by their due dates.  Often times we encounter clients that leave these bills unpaid, thinking that they are the responsibility of the at-fault party.  While this is true and the at-fault party will eventually pay for the bills, the bill is still the responsibility of the person who received the treatment in the eyes of the healthcare provider, and they will forward any unpaid bills to collections.  Therefore, you should pay any outstanding bills now so that your credit is not harmed and then expect to be reimbursed for them later when you make your personal injury claim.

Charitable Write-Off Amount

Many hospitals will have specific policies in place for billing patients that received treatment and did not have health insurance.  They have requirements where if you fall below a certain income threshold, they will write-off either a significant portion of the bill or the entirety of it.  This differs from a contractual adjustment.  California law allows the charitable write-off amount to be included in your personal injury claim.  Your bill must mention some sort indication of “charity” in the itemization in order for that amount to be included.

Example

You are involved in an accident where you had an emergency room bill for $5,000, and spent $25 for prescription medication.  You receive a copy of the bill that shows:

– health insurance payment of $3,500
– contractual adjustment of $1,400
– outstanding balance of $100

Your personal injury claim would entitle you to $3,625 for the medical bills portion.


If my health insurance paid for my medical treatment, could they make me pay them back from my personal injury claim?

Yes.  Everyone who has health insurance, whether they know it or not, has agreed in their policy to pay back their insurance for any treatment that they paid for that was a result of a third-party personal injury claim, which they received money for.  This process is called subrogation.  Although health insurance providers have a contractual right to this money, personal injury lawyers can negotiate and substantially reduce the amount.  Additional information on subrogation can be found here: Health Insurance Subrogation Claims


For any questions about what you are entitled to and how a personal injury lawyer can help reduce your health insurance provider’s lien amount, give us a call at (415) 345-4282 or submit an online inquiry and we are happy to answer your questions.  All our consultations are free.