My 9 year old daughter is playing with friends. They're roughhousing, and as I watch, she falls, hitting the back of her head on concrete. As a former EMT, I saw signs of a potential concussion- confusion, dizziness, etc. So I take her to emergency. By the time we reach the hospital, I can see she's fine, but we wait for a doctor anyway. Our doctor's visit lasts all of two minutes before they say they think she's fine as well. I agree, denying further tests, and we go home. All is well. It's kids being kids and stuff happens.

Within a few weeks I receive a letter from a company called the Rawlings Group, a health care subrogation firm. It is a page long questionnaire asking if we have contacted a personal injury lawyer, who's property the accident happened on, if we will be pressing charges, is it work related, all sorts of information about the accident...I ignore the letter, not knowing if it's legitimately connected to my health care (Kaiser).

Then another comes.

Then another, now from Kaiser, claiming I am breaching the terms of my health care agreement by not providing this information to Rawlings.

So I look into all this further. It seems Kaiser now immediately turns cases over to Rawlings, who then goes on to try and recoup money from another party for Kaiser. AKA: Looking for someone to sue.

This whole deal makes me sick.

My wife recently went to the doctor, trying to figure out some sciatica-like pain she was having. Rawlings is now contacting us about her visit, with the same form to fill out- did this happen on someone else's property etc.

Now I'm really getting sick.
It seems the whole world is now out to sue somebody.

So, in my daughter's case, if the accident were on someone else's property, will they be getting contacted by a lawyer now, whether I like it or not? Are these companies going straight after homeowner's, employer's, or school district's liability insurance now, so that Kaiser can keep a greater share of the ridiculous amount of money I have already paid them...All whether or not the actual victim thinks there was wrongdoing?

Is this now the new standard, everyone trying to recoup losses from someone else, with the lawyers of course taking a cut, and all the while still charging me for services?

Anyone else find this deeply troubling?

Edit...grammar.

Edited by xnomanx on 08/26/2012 13:00:21 MDT.

This is not new at all. Rawlings does this all over the country. They are unlikely to sue anyone; instead they wait to swoop in on the money recovered by the injured party. The way it usually works out is as follows: 1.Injured party hires a lawyer to pursue her case 2.Injured party gets a verdict or settlement 3.Rawlings rides on the coat tails and demands a large part (or all) of the injured party's verdict or settlement 4.Injured party loses the amount it recovers, even amounts for lost wages, pain and suffering, etc. because the policy allows them to get it all.
I am a personal injury lawyer and have the pleasure of dealing with them regularly. Federal law has given them special status to take everything, even where the recovery by the injured party is limited.

"Federal law has given them special status to take everything, even where the recovery by the injured party is limited."

Did they coincidentally give large political contributions before the law was passed? Or after?

It feels new to me...after a lifetime of emergency room visits, these are the first times I've ever been contacted like this.

Edit...
So if I understand you correctly, if a person gets an injury settlement, Rawlings goes after that settlement (or a portion), gives some back to Kaiser (or whoever they're representing) to recoup losses, and keep a chunk for themselves?

Edited by xnomanx on 08/26/2012 13:20:50 MDT.

You can see this better if you twist it around differently from the case of the nine-year-old. Suppose that there was a hazard on the property that the property owner knew about. Then if the nine-year-old were hurt and went to the emergency room, there is the possibility of a real injury, real pain and suffering, real medical costs, etc. Who should be responsible for those losses? Hint: it isn't Kaiser. The negligent property owner or his insurer is probably responsible. The family of the injured nine-year-old may or may not be trying to sue the negligent property owner, but if that is who is really responsible, then some entity needs to push that to happen. Suppose that the family of the nine-year-old sues for a million bucks and that is settled out of court. Kaiser is still left holding the bag for the medical costs.

So, there is a purpose behind having somebody looking into injuries and responsibilities.

--B.G.--

"This whole deal makes me sick."

Be careful, if you get too sick and go to the doctor then you may get another letter!

Good points Bob, but I guess what ultimately doesn't sit well with me is the question of whether or not these practices are in place for noble purpose of determining responsibility and recouping "losses" or whether they are simply about maximizing profit (with an outside agency taking a healthy cut on the side)?

Craig, I have my opinions about this, but I am just another interested Kaiser member. Kaiser does not want to get stuck holding the bag for millions of these injuries and their costs, because then it would have to raise rates and all that. Instead, if they have this outside company sniffing around, they can get it sorted out as to if there was somebody negligent and responsible, or whether it is an ordinary accident and Kaiser will absorb the medical costs. If they determine that you are suing the responsible party, then Kaiser will want to get in line for its medical costs to be reimbursed.

Once many years ago I was injured while traveling on business. Kaiser got stuck with some thousands in medical costs. Later, some outside company contacted me for the facts of the matter. But then they couldn't really pin any fault on anybody, so the whole thing dissolved.

I'm not sure that anybody is trying to maximize profit. It is more about minimizing losses if they aren't your fault.

--B.G.--

Edited by --B.G.-- on 08/26/2012 14:09:45 MDT.

nm

Edited by xnomanx on 08/26/2012 16:06:13 MDT.

I am also a keiser member and I have never been contacted by Rowlings even though I have been in and out of the hospital for about the last 4 years. If your insurance is provided by your imployer they might added Rowlings to the contract.

I could be wrong but I believe that the subrogation language means they get to recoup what they spent on the medical care out of any settlement you get from a lawsuit. The irony is that you spend that premium for insurance thinking that means they will pay and what it ends up is that they take the money you got to make up for lost wages, disability, pain and suffering etc to replace the money they spend and you get zip but the care you paid for already with your insurance premiums. I don't think it is a law so much as some fine print in your policy

This is the first I have heard of such a practice. And, yes, I too find it disturbing. It's hard to fathom how this sort of thing might eventually affect our daily lives. (BTW any previous invitation offered for your kids to come play at my house, either expressly stated or implied, is herewith rescinded. You will understand of course.)

It's very likely your auto or health insurance contract has such a clause. The one that I remember seeing (Geico/Aetna/some other company) has language along the lines of "you agree to cooperate, etc, etc, should we need to sue someone to recover damage".

I suspect the non-exclusion of "pain and suffering" amounts is to prevent someone gaming the system by negotiating a settlement with the insurer of the at-fault party and persuading them to classify the bulk of the amount as "pain and suffering" rather than for medical expenses. Besides, you should get your deductible back if anything's left after the medical costs are covered.

When one considers the massive costs of health insurance, it seems only fair that your insurer should be able to place the costs on the party at fault. Sure your insurer gets to eat the cost if you're at fault, but why should they pay for someone else's screwup? Isn't that what personal responsibility is all about? Lawsuits just happen to be the proper legal forum for sorting such matters out if a settlement can't be reached. After all, we aren't a bunch of communists where Uncle Joe pays for our health care expenses!


(Not intended /entirely/ seriously, of course.)

Subrogation is really not a particularly new concept. The insurance company hires Rawlings as a third party contractor to do its dirty work. Federal law does allow health insurance plans broader subrogation rights than most others are allowed under state law. I would agree with Bob that there is some fairness in subrogation as a concept but, as a practical matter, it can be applied very unfairly. There are often practical limits of recovery, for example when an at-fault party has less insurance coverage than you have damages; this is pretty common. Also, apportionment can reduce an injured party's recovery, also pretty common. In those situations, the health insurer may get most of the injured party's recovery.
The implications of subrogation vary with every case. Sometimes it will seem fair and other times not at all. Its a subject that can get quite complicated and keep a guy like me busy for a long time. And we haven't even touched Medicare subrogation..ick.

Craig posted:

Edit...
So if I understand you correctly, if a person gets an injury settlement, Rawlings goes after that settlement (or a portion), gives some back to Kaiser (or whoever they're representing) to recoup losses, and keep a chunk for themselves?

Exactly right, Craig.

Edited by alexdrewreed on 08/27/2012 09:29:05 MDT.

Craig,
From what you explained it looks like Kaiser is breaking Federal HIPPA laws sharing patient private health care records with the law firm of Rawlings group. I doubt Rawling group is part of the Kaiser HMO group.

I think I would contact a lawyer see if Kaiser is breaking the HIPPA laws forcing patients to share private health care information with a outside law group like Rawlings group who is hunting for law suits to make money back for Kaiser and for the Rawlings group.

Also who's to say your private health care information is secure and can't be shared inadvertently with other third parties through the Rawlings group a legal firm not a health care firm.

It might just be a misguided board of directors of Kaiser who signed this contract with Rawlings group to further the profits of Kaiser Hmo Group. Kaiser may be forced to sever ties with the Rawlings group in class action law suit or actions by the attorney general.

Terry

"Anyone else find this deeply troubling?"

In Cronin's "The Passage", children are nurtured in 'the Sanctuary' until they are 8 years old. In this protected environment, they live a fantasy life which includes such virtues like truth, honesty, valor, etc.

However, upon their 8th birthday, they are taken aside and told the truth: the world is a vicious place, where life in actuality is nasty, brutish and short. At that point, they go through an accelerated process of the 5 stages of grief, beginning with denial, but eventually reach resolution.

The story is of course an allegory for our own very real existence. My suggestion is to accept the world as it actually is, and work towards thriving, not just surviving. Once you know the game, it's literally child's play competing against those who somehow just can't let go of make believe.

Edited by Hobbesatronic on 08/27/2012 11:30:09 MDT.

I just got an email posting for a health care subrogation continuing education seminar. It's on the exact subject that disturbed Craig:

The speaker has been involved in the resolution of roughly 5,000 subrogation/reimbursement claims in the past 6 years representing both plaintiff's and health plans. He will share his knowledge this complicated healthcare transaction as well tips and tactics for limiting or defeating subrogation/reimbursement claims by ERISA qualified health plans.

As you can see, its a common and complicated practice.