An estimated 18,000 traffic fatalities involved alcohol, drugs, or both on American highways in 2006, the latest year for which such figures are available.
Thousands more were rushed to trauma centers for emergency care and extended hospital stays well into six-figure dollar amounts.
In most cases, insurance claims covering accident victims – 65 per cent – will be paid. It’s the other 35 percent that hospital administrators worry about. Those admitted to trauma and burn centers with impairing substance levels in their system maybe denied insurance coverage. Insurers can refuse to pay the medical claims of those who test positive for drugs and alcohol.
Rising healthcare costs and the growing number of defaulting insurance companies are jeopardizing the future of both public and private hospitals with unpaid millions in uncollectible bills. The Regional Medical Center of Memphis (The Med) is one among a number of hospitals across the state buckling under the costs of default insurance claims.
“Basically, many medical insurance forms include a clause which frees the insurer from liability in cases involving substance abuse,” said Vickie Trice, of the Tennessee Department of Commerce and Insurance public information office. Some will pay the claim, but a significant number refuse, leaving hospitals to absorb the costs.”
Medical facilities are stuck with hundreds of thousands of dollars in ‘uncollectible accounts each year. Several individual bills even run into the millions.
“Trauma victims in the Mid-South will automatically be brought to The Med,” said Vice-President Sandy Snell of Communications and Marketing. “Some don’t have insurance. Others are covered by insurers who refuse to pay. Since individuals most likely could not possibly pay, these accounts are sent to attorneys who specialize in overturning these kinds of denials.”
There are no claim default statistics, but doctors and hospitals in Tennessee fear an increasing number of insurers will begin using the clause.
At Vanderbilt University Medical Center in Nashville, officials estimated that about one in three victims brought to the hospital for trauma treatment annually are substance impaired.
Last year, state lawmakers adopted a resolution asking that a review of Tennessee alcohol and drug laws be submitted for possible reform. The report is due Dec. 1.
Laws mandating the payment of such claims have been enacted in the District of Columbia and 13 states: Colorado, Connecticut, Illinois, Indiana, Iowa, Maine, Maryland, Nevada, North Carolina, Oregon, Rhode Island, South Dakota, and Washington.
North Carolina, the only state in the southeast region with such legislation, passed a law in 2001 prohibiting claim default on the basis of impairment. But not all insurance polities are affected.
Chrissy Pearson, director of public information for the North Carolina Department of Insurance, said under North Carolina law, an insurer may not refuse to pay a claim based on substance use found in the blood.
“But the policy must be comprehensive, covering hospital costs, surgery and other medical procedures,” said Pearson. “If policies cover only accidents or just pay out a dollar amount for each day in the hospital, insurers may choose not to pay at their discretion.”
According to a recent report published, The Tennessean newspaper in Nashville, carefully choosing insurance companies makes a difference. The newspaper’s inquiry found:
As the state’s largest health insurer, BlueCross BlueShield of Tennessee, claims are not denied based on intoxication. And in September, the insurer will discontinue a policy that allowed it to deny claims related to an injury occurring during the commission of “a felony, an attempted felony, riot, or insurrection.”
Aetna does not deny substance-abuse claims, but may sometimes seek restitution from the person responsible for causing the accident.
UnitedHealthcare does not have a clause written into the language of insurance contracts and will not likely include it in the future.
Dr. Julie Dunn, director of trauma at East Tennessee’s Johnson City Medical Center, told The Tennessean that Alcohol and urine-sample tests for screening were eliminated after an insurer refused to pay the claims of a man who became a quadriplegic from injuries sustained in a fall at home. He had consumed several bottles of beer.
Said Dr. Dunn, “It’s not in anybody’s best interest to deny such a claim.”
NOTE: Traffic crashes account for about 20 percent of the nation’s traumatic brain injuries. African Americans have the highest death rate from these severe head injuries, according to a report by the Brain Injury Association of America.
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