Slowman wrote:
i don't know until i dig into this, but it *might* be that he entered as a professional. in this case they might deem it a work related clamp - a work comp exposure rather than a health insurance exposure. but then there might be an exclusion in the policy for athletic competitions. i don't know. so far i've never heard of a health insurance claim getting denied an athlete because he's an athlete. i also thought USAT's medical payments was $75k, not $25k. i want to look into that as well.
finally, there's the $256k price tag. i've always been extremely, militantly, subversively antithetical to the idea that those with the most exposure get hit with a bill that's 4x the price paid by medicare, BX, et al.
i just would like to see if there's a way out of this that keeps everybody whole and makes everybody behave in good faith.
This is a question of state law. Worker's comp typically only applies in an employer/employee relationship. I think it would be hard for a pro triathlete to establish such a relationship, but who knows? The burden is on the employer to provide some level of coverage for injuries/death/disability without the worker having to establish employer liability for the injury. In turn, an employee typically may not bring an action for negligence against his employer. In terms of its relationship to health insurance, most state insurance codes establish the workers comp carrier as the primary payor, which does NOT mean that the health carrier can deny a claim, only that it gives the health carrier a lien against any recovery from the workers comp carrier. Also, our insured here should get some of the worker's comp lien reduced as he is in effect acting as a collection agent on their behalf.
I wish our boy best of luck and a full recovery but he needs legal counsel now.
best,
Paul