Funding for brain injury rehabilitation services and supports may come from a variety of sources, depending on the nature of the brain injury, how it was sustained, and how old the person was at the time of injury. Private and public healthcare programs often pay for the initial medical and rehabilitation costs associated with inpatient admissions. Outpatient benefits, however, are often limited in scope or time, and additional resources are available through the Commonwealth of Pennsylvania (see also, State Agencies).

Health and Accident Insurance

When a traumatic brain injury accident occurs, it is usually the first time that anyone looks at their health or accident insurance policies. All policies should be closely examined, particularly for the following items:

• What are the limits of the lifetime benefits? 
• Is there a $1,000,000 lifetime maximum under the health insurance policy?
• What is the deductible? 
• Will the policy pay 100% of each medical bill or only a percentage? 
• Is there a gap in coverage, so that the first $10,000.00 in medical bills are excluded?
• What are the "exclusions" in the policy?
• The exclusions are usually printed in fine print on all insurance policies.  There is a saying in insurance law
• What the big print giveth, the small print taketh away."  With respect to exclusions that is true. 
• Does the health and accident insurance policy pay for only hospital care, or does it pay for care and rehabilitation facilities, transitional living program, skilled nursing care and long term care in a nursing facility?
• What is the definition of rehabilitation services?
• Persons with a traumatic brain injury are going to need outpatient rehabilitation services.
• Does the "health and accident" insurance company have an option of terminating coverage? 
• Is it the insurance company or their doctor that determines that a person is no longer making progress as the result of rehabilitation services?
• How are the benefits coordinated? 

Typically, insurance policies provide that health or accident insurance has to be coordinated with any insurance that you have so that when you have two insurance policies, which one is responsible?

Bills will be submitted first to the primary carrier who has to pay the bills according to the insurance contract.  Any remaining bills are forwarded to the "secondary" insurance carrier.  It is often very difficult to determine which carrier is primary and which is secondary, especially when there are enormous bills and a traumatic brain injury: neither insurance company wants to assume responsibility.  In such instances, the assistance of an experienced attorney is critical.

Is there a major medical carrier, HMO or some type of private health or accident insurance which will pay medical bills if there is a catastrophic injury such as a brain injury? 

As soon as possible after the injury or illness, you should get a copy of the insurance policy and plan booklet and find out whether the insurance company will cover rehabilitation expenses, skilled nursing care, transitional living programs, etc.  This policy should be reviewed by your attorney so that you can make adequate discharge planning decisions and properly fill out the application and proof of claim forms. Is there coverage under the homeowner's insurance policy or an umbrella/excess policy? 

Many homeowner's policies provide coverage which pay a certain amount of medical bills, regardless of how the injury occurred, so long as it happened on the premises of the homeowner.  Accordingly, homeowner's insurance policies, and any excess or umbrella policy should be carefully examined to determine whether or not there is medical coverage under the terms and provisions of that particular policy.  This needs to be done promptly because many policies contain language requiring notice of injury or proof of claim being filed promptly.

Workers Compensation
   
Workers Compensation Benefits are paid if a worker is injured on the job.  In today's society, "on the job" can mean any activity that is job-related.  The accident need not occur on the employer's premises, but can also include injuries while traveling or at a company social function.  It is important to make certain that the accident is reported to your employer and that your employer provides workers' compensation benefits. Many workers and their families are told by the employers to apply for group insurance benefits, when you really should be covered by workers' compensation.  Group benefits which are also called "sickness" or "accident" benefits are disability benefits.  But if the injury is work related, you should apply for workers' compensation benefits. Workers' Compensation Benefits are superior to group benefits because:

• Workers' Compensation Benefits are not subject to income tax;
• Depending on the state law, the disability benefits under the workers' compensation can be paid for a much longer time than group disability benefits;
• Workers' Compensation Benefits are typically paid in a higher amount than group disability benefits.  And, if you are receiving workers' compensation benefits, and you return to work at a lower rate of pay due to your injury, in many states you are entitled to weekly compensation benefits equal to 2/3 of your pay.  Group benefits do not provide for such partial benefits.

Workers' Compensation Benefits, in some states, pay all of the medical expenses with no limitation.  Medical payments under BC/BS, HMO or similar coverage, are limited.  This means that under group benefits coverage, you have to pay those medical expenses which are not covered by the health care insurer.

If you are injured on the job and are not awarded Workers' Compensation, you need to contact a lawyer immediately and file for Workers' Compensation. How long can you receive Workers' Compensation Benefits? Typically, the Workers' Compensation law requires that your
employer's insurance carrier pay for all reasonable and necessary medical treatment that is related to the work injury.  You also are typically entitled to receive a percentage of your wages as set forth under the state law.  Can you receive Workers' Compensation as well as other insurance coverage for your injuries? Generally, your employer is only responsible for Workers'
Compensation Benefits.  However, if unsafe products or dangerous working conditions contribute to your accident, an attorney can determine whether there is additional insurance coverage available to compensate you for the injuries.

Auto Insurance

State laws regarding medical insurance available for traumatic brain injuries sustained in an auto accident vary.  Typically, the insurance carrier for the vehicle that you (or your family) own pays your medical bills, if the policy provides for such coverage. If you do not own a vehicle or live in a household with relatives who own a vehicle, then under certain state laws your medical bills may be paid under that policy.  If there is no motor vehicle coverage in the household, typically medical bills will be paid by the auto insurance carrier for the vehicle in which you are a passenger when the accident occurred.

It is important to know that under the typical auto insurance policy, there is very limited "health" insurance coverage. In Pennsylvania, this is referred to as the "1st party Medical Benefit", and only $5000 in coverage is required. What happens when the insurance benefits under the auto policy are exhausted? Once the insurance benefits under the auto policy have been paid out, if you have other health insurance, your bills will then be paid through that health insurance carrier.  If not, then you need to apply for insurance benefits or Social Security, Medical Assistance and/or Medicare. 

What rights do you have to collect other compensation for injuries caused in a motor vehicle accident? Catastrophic automobile accidents are caused by the drivers, the vehicle, the roadway, or some combination.  Accordingly, an investigation needs to be undertaken to determine the causes of a catastrophic injury.  Only an experienced attorney can properly and effectively investigate and analyze the matter. The drivers involved in the accident may have some responsibility to compensate you for injuries and losses.  If the drivers do not have auto insurance, you may be able to receive benefits from your own auto insurance policy through the "uninsured motorist coverage" in your own policy.

Additionally, claims can be brought against others.  Products liability cases can be brought against the manufacturers of the vehicle if a defect in the vehicle caused the traumatic brain injury accident.  Claims can be brought against the state or municipal highway department if the roadway is unsafe (one of the so-called "killer highways").

In certain circumstances, an investigation needs to be undertaken to determine whether any of the drivers were intoxicated, and whether any bar or other person is responsible for having continued to serve an intoxicated or minor person.  A professional investigation by an experienced attorney, along with investigators and forensic experts must be undertaken regarding the safety of the vehicle, the safety of the roadway and other circumstances surrounding the accident.