Worker Comp vs. Primary Medical Plan

[ktn5519]

My workers compensation claim was made in the State of: California
My primary medical insurance is asking if my recent visit with them is part of an auto accident during work. Am I obligated to provide this information? If I do not give them the information, what would happen? Thanks.

[BvIA]

Of course you must divulge the reason for your claim on GHP/Group Health Plan, work injury is expressly exempt from coverage in GHP.

If the injury is from MVA and work related, your ER's WC coverage should be providing benefits/treatment. They will place a lien on any recovery you may see from the PI/MVA case. Refusing to cooperate with the GHP could/would result in denial of coverage.

[ktn5519]

Thank you for your reply. I understand that primary insurance wants to recoup their cost from WC insurance. Could primary insurance use the WC medical info one provides to them to later (down the road) deny treatment for reasons that future medical issues resulted from a previous WC injury?

[BvIA]

Yes. Your GHP covers you, and non industrial injury/illness....your ER is responsible for treatment to your work injury.
Knowing your GHP expressly exempts coverage for a work injury, and permitting a provider to bill for services could be construed as an attempt to defraud the GHP...you don't want that to happen.\

If anyone at the GHP tells you to go ahead and use the coverage... GET IT IN WRITING.
If you settle the WC claim, and take a lump sum payment for future medical reibursement, then use the GHP, it would be double dipping...again, fraud.

[ADJ]

If you knowlingly do not provide information that is essential to the payment of benefits, then you are committing insurance fraud. You can be prosecuted for this crime.