If you have private health insurance, your private health insurance company is required to pay for your medical expenses until the Adjudication Division determines whether your accident or injury is related to work.
You need to let the Adjudication Division know that you have private health insurance and you want them to pay for your medical bills while your workers compensation claim is being decided. You’ll need to provide the following information to the Division:
Once the Division has this information, it will send a notice to your private health insurance carrier, letting them know of their duty to pay. It’s the Division’s responsibility to send that notice – you don’t need to. You can let the Division know this information at any point in your case, but please note that your private carrier won’t be responsible for expenses until they receive notice, and they may not reimburse you for expenses you’ve incurred up until that point.
Please note that many private insurance carriers are not subject to the Coordination of Benefits Act. If you receive private health benefits through an employer, and if that employer is “self-insured,” then they do not have to pay for your medical expenses until the Adjudication Division determines whether your accident or injury is related to work. On the other hand, if your private health insurance is “fully-funded,” then they are required to pay for your medical expenses.
The easiest way to find out if your carrier is subject to the Act is to ask your HR representative if the company is “self-insured” or “fully-funded.” Or, you can call the number on your insurance card and ask the insurance company directly. Please note, however, that the Labor Commission is not in a position to help you find the information.
The Labor Commission will send notice of your claim to your private insurance carrier regardless of whether they are self-insured or fully-funded so long as you provide us with their contact information and your policy number. Please recognize that if the company is self insured, it could still pay benefits while your case is pending based on the company's own internal requirements, however, it is not required to pay by the Coordination of Benefits Act.
Your private health carrier is only responsible for your medical bills to the same extent it would be if your accident or injury weren’t related to work. In other words, if your private health insurance policy doesn’t normally cover certain procedures or expenses, it’s not obligated to cover those expenses just because you claim that accident or injury is related to work. You will also be responsible for any co-pays or deductibles you would otherwise be obligated to pay.
Once the Adjudication Division reaches a final decision in your case, it will let you, your employer, the workers compensation insurance company and your private health insurance company know. If the Division decides that your accident or injury is work-related, the workers compensation carrier will be required to repay your private health insurance carrier in the amount the plan paid to the health care provider. It will also have to pay interest at the rate of 8% per year from the date the health benefit plan paid the medical claims until the date the workers’ compensation carrier reimburses the health benefit plan.
If the Division decides that your claim is covered by workers compensation, the workers compensation carrier will also be required to reimburse you for any co-payments, coinsurance, deductibles, or other out-of-pocket expenses that you’ve paid or incurred. They will be required to repay you interest accrued at the rate of 8% per year from the date you paid the expenses until the date the workers' compensation carrier reimburses you.
The workers compensation carrier must pay the reimbursements within 15 days of the date the Order becomes final. Orders generally become final 30 days after they are issued, unless there is an appeal in which case the Order won’t become final until after the appeal has been decided.
If the workers compensation carrier does not make the payment as required within 15 days of the date the Order becomes final, the private health carriers and/or you may file a Workers' Compensation Coordination of Benefits Untimely Payment Complaint Form with the Utah Labor Commission’s Industrial Accidents Division. You can get the form here: http://laborcommission.utah.gov/divisions/Adjudication/WorkersCompensationHearingForms.html.
If your claim is found not to be compensable, the workers compensation carrier is not required to reimburse your private health insurance company for the benefits it has paid under the terms of your health benefits plan. Likewise, the workers compensation carrier is not responsible to reimburse you for any co-pays, deductibles or other expenses you may have had to pay.
You, your employer and the workers compensation carrier remain free to reach a settlement agreement in your case, and agree that the case is covered by workers compensation insurance or not. If you agree that it is covered, the workers compensation carrier will be obligated to reimburse you and your private carriers as discussed above. If you agree that the case is not covered by workers compensation, then your private carrier is not entitled to any reimbursement from either you or the workers compensation carrier. Please note that the Division is obligated to provide your private health carrier with a copy of your final settlement agreement.
No. Private insurance companies will not be added as a party to your workers compensation case, and other than sending them notices at the beginning and end of your case (and any settlement agreement if applicable), the Division will not provide them with copies of any documents in your case. Likewise, you, your employer and the workers compensation insurance carrier are not required to send the private health carrier copies of any documents. Representatives from your private health carrier may attend the hearing as members of the public, but they will not be allowed to make any arguments or present any evidence.
The private insurance company may send notice to the Division and the parties that it has paid a claim under the Coordination of Benefits Act, but it is not required to do so. Filing such notices will have no impact on the private health carrier’s rights and responsibilities, and other than filing their notice of payment in your case file, the Division will do nothing with them.