Legal Question in Personal Injury in Texas
how to calculate ''medical specials''
Had fx ankle & dislocation/surgery w/ nails/ plate after car hit me. Allstate(their insured negligent driver) accepted full liability. Have health ins which paid for all. When using multiplier to calculate damages do I use what the hosp, MDs, ambulance, PT actually charged or what was paid by my health insurance? For example, the surgeon charged 3,400 but ins contracted with them to pay 1200 for ankle surgery. So would I use the $1200 or $3400? Seems if one has really great insurance then damages would be diminished??? So far BC/BS has paid over $7,000 but the actual bills (if not contracted) are greater than 20,000. If I use a mutiplier of say 5 there is a big difference (35,000 compared to 100,000) for my ''demand letter''. Thanks in advance for answering my question.
2 Answers from Attorneys
Re: how to calculate ''medical specials''
There is no magic formula on how much pain and suffering an insurance company will pay you. They're job is to pay you as little as possible. As for the paid or incurred, your attorney will argue "incurred" while the insurance company will argue "paid". Your BCBS probably has reimbursement rights in it. This means that you'll have to repay them. There is a doctrine of law that allows some reduction for collecting their money for them. HOWEVER, a recent Texas Supreme Court case says that if your policy states that they get fully reimbursed, then they may not have to reduce. I strongly recommend against your doing this yourself, an experienced attorney may be able to get you more compensation (even including the attorney fees) than you could get yourself. Plus, you are about to step in a mess with respect to the health insurance issue.
Re: how to calculate ''medical specials''
Due to your injuries, you should really consider hiring an attorney. Without a lawyer, you don't have much leverage. That should hold down the amount they are willing to pay you. You will have to repay BC/BS and it will usually allow a reduction for attorney fees. Another reason for you to hire an attorney.
In regard to medical bills, the law provides for recovery of bills paid or incurred. As you might suspect, there has been some debate about how to interpret this. Regardless, the insurance company will only give you credit for the paid amount.
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