"Dear [OP]
This letter will formally notify you that Priority Health has retained Optum to pursue a recovery for medical benefits that have been or may be paid by them on behalf of [OP] for the treatment of injuries sustained arising out of the above captioned injury. Please contact us prior to settlement to obtain the total amount of paid benefits.
The plan has a right to pursue other sources of payment, such as insurance companies, for reimbursement of the medical benefits it has paid. We are investigating to determine if any other party or insurance carrier may have responsibility for this occurrence. Please complete the enclosed questionnaire relating to your injury. If another individual or organization contributed to or caused your injury, they may be obligated to reimburse your health plan for the medical payments. Please return the form to me after you complete it.
If you have retained an attorney, please have your attorney contact this office and acknowledge receipt of this letter. In the event you have already made a monetary recovery from some other party or insurer in addition to your health plan do not spend the money and notify us immediately, as we assert a subrogation and/or reimbursement interest on any settlement proceeds. Please feel free to contact our office if you have any questions. Thank you for your assistance.
Sincerely,
[PERSON'S NAME]
Recovery Specialist"
I got this letter from a company called Optum in the mail along with a form and a list of my medical claims related to my broken arm from May. The amount billed is all correct but the amount paid doesn't line up with me or the amount the hospital attributes to insurance.
I'm so confused. It happened at my grandparents house so his insurance paid a small amount to reimburse him because he insisted on paying for the surgery but that's all that's happened. I don't want to stress him out of this is nothing but I'm panicking.
Is this a scam?? This isn't my insurance company.
byu/RefrigeratorOk6907 inInsurance
Posted by RefrigeratorOk6907
7 Comments
As a insurance adjuster – I can assure you optum is very real cause they call my line every 10 minutes 😂
Priority Health isn’t your insurance? They want to recover the rest of what they paid from your grandparent’s home insurance.
Since grandparents insurance is liable, your insurer wants to recoup their money.
It’s a lien letter stating that if/when you pursue a liability claim against your grandparents, and if you get a payout, the health insurer gets dibs on what they paid-out on your behalf.
So for example if you got a $90k settlement, and your medical bills were $30k, the letter is saying that they want their $30k back from your $90k settlement.
This is pretty standard. Your health insurer almost always has the right to do this.
If you don’t actually pursue a liability claim against your grandparents then the health insurer may not be able to do anything about it.
If you tell us where you’re at a homeowners liability adjuster or medical subrogation adjuster here can tell you whether the health insurer can pursue your grandparents independently of any claim you’re *not* making.
His insurance paid HIM because he insisted on paying for the surgery? That’s wild.
There’s claims on file that Priority Health paid for, they’re entitled to recoup their costs either by taking money from your settlement or denying the claims because they aren’t responsible given your grandparent’s homeowner insurance is liable.
This is a very standard industry letter.
It’s called subrogation, the most common thing that many have never heard of, they own your rights to recover against anyone who COULD be liable, even if you would never sue your family member, they can, and they do so, via stepping in your shoes, as they call it, it’s a common law and contractual right in most cases. Varies by state as well.
Your grandparents would be wise to remit any separate demand letters that arrive to their homeowners’ insurance but they should also consult with an attorney to confirm the best course of action and not some stranger on the internet but that also may not happen.
For now, it seems like only a questionnaire to see what happened and determine if there is any liability from them in which to pursue, you just answer honestly. Lying to an insurer is bad news.
This does not automatically mean your grandparents are liable, but insurance wants to see if there is any chance at recovery, they also want to put you on notice if you sue or make demands against their insurer that they usually have some right to be involved in that, as well as possibly recover from you and any proceeds, and if you keep them in the dark.
Worst case homeowners’ is supposed to defend these types of claims either way, should they follow through, and provided it is a covered claim and there was no fraud or intentionality. Their insurer probably paid out med pay coverage for your $1k, not totally sure there, but that’s a separate coverage from liability which should be the coverage for any addition actions. That will get factored in and it would be good to know if there were any conditions attached to that payout, such as being written up as a settlement or a waiver of claims, as that could complicate things.
Sounds like you caused an accident, the other party’s insurance paid for their medical bills, and you’re being subrogated against. Contact your insurance at the time of the accident and see if you have coverage. They have a duty to defend if so. Otherwise, retain an attorney ASAP