Severe brain injuries don’t just impact the victim; their entire family suffers. Family members may be thrust into the role of caregiver, or if the injured person was the family breadwinner and is now unable to work, the family is left in financial straits.
Navigating the traumatic brain injury insurance claims process is challenging, especially for a victim who may be unable to advocate for themselves. Many people do not receive everything they’re entitled to because they either try to represent themselves or hire an inexperienced attorney.
Our San Luis Obispo brain injury lawyers are among the best in the state, and we can help you file and appeal insurance claims or file a suit for damages against the party that caused your brain injury.
Types of brain injuries
Brain injuries can happen in one of three ways:
- Blunt force head trauma
- Penetrative head and brain trauma
- Hypoxia, or oxygen deprivation damages brain tissue
Brain damage may also occur due to a degenerative disease or suddenly after an aneurysm or stroke.
Insurance coverage for options for brain injuries
Insurance policies differ in coverage for brain injuries, so it’s important to read yours closely to see its benefits and limitations. You’ll likely be affected by the following elements of your policy:
- Lifetime coverage limit, which a brain injury victim may reach fairly quickly
- Subrogation clauses, which provide someone else the right to act on behalf of the policyholder concerning legal actions regarding the insurance contract
- Therapy benefits, stating the number of visits allowed per year (many brain injury victims require occupational or physical therapy)
- In-home care benefits, including the amount allowed each year for a hired caregiver or home health nurse
- Durable medical equipment, stipulating which types are covered and under which conditions
Some people with brain injuries may be eligible for California Medicaid, especially if they cannot work due to the injury, lose their employer-sponsored coverage, and now meet income eligibility for Medicaid. Medicaid covers more than just the doctor’s appointments; it also pays for most or all the cost of in-home health care or residence in a nursing home.
Navigating the claims process
Filing traumatic brain injury insurance claims is the same filing process for any other type of injury. Providing the right supporting documentation for your claim is essential to ensuring that all your required services and care are covered. This includes:
- All medical records, including initial diagnosis and follow-up appointments that monitor the victim’s improvement
- The treating physician’s estimate of the victim’s maximum medical progress (will the recovery have permanent limitations?)
- All medical bills to calculate the cost of treatment
- A log of how the injury has affected the victim’s quality of life, mental and physical abilities, and ability to work or go to school
Insurance companies usually pay only for treatment deemed “medically necessary.” Your loved one’s doctor can help you provide proof that their recommended procedures or care are medically necessary and therefore should be covered.
Challenges in the claims process
Brain injury victims face several hurdles in getting the right insurance coverage for their injuries. The first is having the injury covered, period. How the victim received the injury determines which insurance policy covers them. Workers comp may cover a workplace injury, while a TBI sustained in a car accident may be covered by an auto insurance policy (the victim’s or the other driver’s).
Proving how badly someone is injured is another difficulty. Insurance companies are notorious for minimizing claims or even denying them outright. Claimants need to prove that they should be covered and prove the degree of their injury to receive proper coverage.
If the victim is injured by another party and that person or entity challenges the claim, the situation becomes more complicated. Often in these cases, a brain injury lawsuit is the best recourse for a brain injury victim. Brain injury victims harmed by another party’s negligence or reckless actions have the right to file a personal injury lawsuit for damages. A San Luis Obispo brain injury lawyer can explain your legal options and litigate your case.
Resources for brain injury victims and their families
San Luis Obispo brain injury victims can receive help and support through one or more of these organizations for brain injury victims:
- Brain Injury Center Central Coast (BIC), Camarillo, CA
- Central Coast Center for Independent Living (CCCIL), Salinas, CA
- St. Jude Brain Injury Network, Fullerton, CA
Do you need help pursuing traumatic brain injury insurance claims?
We can help! The San Luis Obispo brain injury attorneys at Ernst Law Group work with California families like yours who have been devastated by the brain injury of a loved one. Contact us today at (805) 541-0300 for a free initial consultation.
