At what point does care relating to a permanent disability that resulted from an accident stop being considered accident-related?
My boyfriend and I were in a car accident (hydroplaned at a very low speed while attempting to merge onto freeway on-ramp, went off the ramp, car rolled across freeway, he was ejected, I was not) at the beginning of 2024 and besides breaking just about everything else, he also broke his spine in multiple places and is now paralyzed (T5/6 ASIA-A complete) from the chest down. No other vehicles were involved, no property was damaged besides his own, and my injuries were relatively minor (in comparison). His auto insurance was minimum coverage and doesn’t cover the accident because in our state, hydroplaning is considered the fault of the driver, regardless of speed/scenario/etc., which they don’t cover.
Long story shorter, our insurance (we work together so we have the same insurance thru our employer) is denying coverage on all of the claims for his care resulting from the accident. Our insurance is actually really good, but because the police slapped him with a charge for the accident (which we are trying to get dropped/dismissed), the insurance company is denying coverage on the basis that they don’t cover injuries incurred during an illegal act. Again, we are in the process of fighting the charge and so hopefully once that’s resolved, we can file appeals for those claims.
EOB Denial Code/Reason on all claims reads: X38 | Acts of aggression or illegal acts excluded.
However, now he’s in the hospital again because he developed a stage 4 pressure wound as a result of progressing HO (heterotopic ossification-he’s basically spawning random bones in his hip/quad muscles, something that just happens for some people after a spinal cord injury; I like to refer to them as his “HO Bones”) that has forced pressure on his right side and prevented traditional offloading from providing sufficient pressure relief.
He didn’t acquire this wound from an illegal act or act of aggression l and I think there’s a fair argument to be made that the accident didn’t cause the wound, his now sedentary lifestyle did, more than anything else. I understand that none of these secondary injuries would have happened if not for the accident, but at what point are these things considered part of his general healthcare as a now paraplegic man, rather than as a result of the accident?
I’m working on appealing the denied claims for his wound-related care, as he has at least 2 months of hospital care and 2 surgeries ahead of him and he’s already being denied from the facilities he’s supposed to be discharged to because insurance is refusing to pay. It will be months before there’s any resolution to the charge related to the accident so waiting on that (especially since I don’t know what that outcome will be) isn’t an option.
Has anyone ever dealt with something similar? How should I go about appealing this?
I already called insurance to talk to them and they said there was no time limit or clause saying how long they will consider the injuries to be accident-related and that it will most likely be determined by his doctors’ notes, etc. I’ve already talked to his doctors to update their notes in his chart to make sure it mentions his condition being caused by his paraplegic status, specifically, which they’re all on-board with.
Besides that and collecting all of that documentation, etc., what should I say in this appeal? I’m just supposed to write them a letter and provide supporting documentation, but I don’t know which details to include/leave out as far as what will help/hurt the situation.
I appreciate any help or guidance anyone could offer!
submitted by /u/parapleaser
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