Column: Sorting out different types of insurance
In Hawaii most people have not one health insurance policy, but three. That’s right.
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In Hawaii most people have not one health insurance policy, but three. That’s right. The vast majority have a general health insurance policy, with either a government-related or a private carrier. Most also have two more policies that fall under the purview of occupational medicine: To drive a vehicle, one is legally required to carry personal injury protection (PIP) or no-fault insurance. It pays for injuries sustained in a motor vehicle accident. Finally, all employees in Hawaii are required to have workers’ compensation insurance (WC), which covers care for injuries on the job.
Don’t feel bad if you haven’t heard of occupational health, the medical specialty that cares for PIP, WC and also third-party liability (TPL), the insurance that covers people who get hurt while riding TheBus, fall in a store or, perhaps one day, while using the rail. Each insurance type is governed by a completely different set of rules. With few exceptions, your primary care provider (PCP) will not treat you if you’re injured in a car or at work, and does not take those insurances.
At Manakai o Malama we have been providing both primary care and occupational medicine services for nearly 20 years. Sadly, we have seen many patients come to us confused and in pain for far too long before they figure out where to go for occupational injuries. Sometimes misdirection occurs in the emergency room, where providers might reflexively refer patients back to their PCPs. Then, after the usual wait for follow-up, patients are informed by their PCP that they must go elsewhere for their occupational medicine needs. Too often, PCPs are not aware of where to refer.
When injured at work, also be cautious of being directed by your employer or insurance adjuster for care at an occupational medicine facility. Decisions may be driven more by an attempt to minimize cost and to get the injured back to work, sometimes prematurely. Also beware of occupational medicine facilities that might unnecessarily prolong care. Trust yourself. Good care should include access to all reasonable, appropriate and necessary services and get you back to work, neither too soon nor to late, but at just the right time. This is to everyone’s benefit.
The decision involving clearance to return to work depends not only on the injury, but also the nature of the job. For a lower back injury, one might return sooner if there is office work available than if heavy lifting is required. Being located near Honolulu Police Department headquarters, Manakai has cared for a great many police officers. For police officers, who are at risk for coming into harm’s way, the bar is higher for return to work clearance. A trigger finger must be 100%, as must be the ability to run.
Given that more than 70% of occupational medicine services treat musculoskeletal injuries, WC, PIP and TPL insurances typically cover acupuncture, chiropractic, medical massage and, for WC, naturopathic medicine. This is in addition to surgery, outpatient medical care, physical therapy, occupational therapy and psychological services if they are reasonable and necessary.
Basics of coverage:
PIP coverage after a car accident allows for a fixed dollar amount of health care, usually $10,000, the legal minimum. Some people have more. Years ago I increased my deductible to $2,000 from $500 and at the same time increased my med pay several-fold with no difference to the annual premium. When the med pay is used up, your private health insurance policy will kick in, but only for services that it covers.
In contrast, WC insurance is not a fixed, but an unlimited resource as long as it is reasonable and necessary. However, WC is subject to highly detailed rules as to what can be done without prior approval on the basis of a treatment plan. Manakai o Malama has a full-time position fully dedicated to processing treatment plans for care authorization.
TPL is more variable. An injury while riding TheBus offers the same coverage limits as the med pay on PIP insurance. However, if you fall in a retail store, some businesses have no coverage, while others will have a range of policy limits.
Hawaii is generally a good place compared with many states for care if you are injured at work, in your car or on TheBus. Remember to work smart, drive safely and look, don’t text, while you are walking. Remember, occupational health care is not the same as general health insurance. When in need, seek care directly at a reputable facility. There are several good ones on the islands.