Unusual question for everyone...I just got off the phone with Premera and I'm not completely convinced by their assurance that I would be covered for a work injury under my circumstances. I'm not injured, but starting a business (a single member LLC) and currently deciding whether or not to elect worker's compensation coverage through WA state. I work in industrial maintenance with rotating machinery, where serious injury is a possibility.
In WA, since I'm the single member owner of my LLC and have no employees, I'm not required to have worker's comp, but I do have the option to elect it for myself. The rates are fairly reasonable, but if my health insurance (an individual Premera plan) will cover me, I don't immediately see the need. So the question is, "if I'm injured on the job, will my health plan cover me?"
Here are two areas from my benefits booklet, under the headings "Individual Medical Plan" and "Third Party Liability/Subrogation."
First they referenced the section on subrogation, explaining that basically they would 'cover a work-related injury as long as there was no other coverage available, or as long as I didn't seek damages from another possibly-liable party.' I will paste the section on subrogation at the end of the post.
Then I found this section:
Individual Medical Plan:
This contract is sold and issued in Washington State as an individual medical plan. It is not issued for use as an employer-sponsored or group health plan. Premera specifically disclaims any liability for state or federal group plan requirements.
This contract does not replace, affect, or supplement any state or federal requirement for worker’s compensation, employer’s liability, or similar insurance. When an employer is required by law to provide or has the option to provide worker’s compensation or similar insurance and does not provide such coverage for its employees, the benefits available under this plan will not be provided for conditions arising out of the course of employment which are or would be covered by such insurance.
The agent on the phone told me that this section is essentially stating that it is a health plan only, and would not offer worker's comp benefits like lost wages, etc. But that's where I'm not convinced. As an LLC owner with no employees, how do I fit into that second paragraph? Could I technically be an employer and/or an employee? And while I'm not required to provide worker's comp, I do have the option. I can imagine a scenario where my claim gets denied because someone determines that I had the option to elect workers comp but didn't, given that paragraph.
The agent's summary was, "as long as there was no L&I claim, you would be covered." That sounds great and fair enough, but still I'm just not sure how thoroughly I need to cover my butt here. Any input would be greatly appreciated...thank you for reading! Section on subrogation follows. -afflab
THIRD PARTY LIABILITY (SUBROGATION)
If we make claims payment on your behalf for injury or illness for which another party is liable, or for which uninsured/underinsured motorist (UIM) or personal injury protection (PIP) insurance exists, we will be subrogated to any rights that you may have to recover compensation or damages from that liable party related to the injury or illness, and we would be entitled to be repaid for payments we made on your behalf out of any recovery that you obtain from that liable party after you have been fully compensated for your loss. The liable party is also known as the "third party" because it is a party other than you or us. This party includes a UIM carrier because it stands in the shoes of a third party tortfeasor and because we exclude coverage for such benefits.
Definitions The following terms have specific meanings in this contract:
• Subrogation means we may collect directly from third parties or from proceeds of your recovery from third parties to the extent we have paid on your behalf for illnesses or injury caused by the third party and you have been fully compensated for your loss.
• Reimbursement means that you are obligated under the contract to repay any monies advanced by us from amounts you have received on your claim after you have been fully compensated for your loss.
• Restitution means all equitable rights of recovery that we have to the monies advanced under your plan. Because we have paid for your illness or injuries, we are entitled to recover those expenses from any responsible third-party once you have been fully compensated for your loss.
To the fullest extent permitted by law, we are entitled to the proceeds of any settlement or judgment that results in a recovery from a third party, up to the amount of payments we have made on your behalf after you have been fully compensated for your loss. Our right to recover exists regardless of whether it is based on subrogation, reimbursement or restitution. In recovering payments made on your behalf, we may at our election hire our own attorney to prosecute a subrogation claim for recovery of payments we have made on your behalf directly from third-parties, or be represented by your attorney prosecuting a claim on your behalf. Our right to prosecute a subrogation claim against third-parties is not contingent upon whether or not you pursue the party at fault for any recovery. Our right of recovery is not subject to reduction for attorney's fees and costs under the "common fund" or any other doctrine. Notwithstanding such right, if you recover from a third party and we may share in the recovery, we will pay our share of the legal expenses. Our share is that percentage of the legal expenses necessary to secure a recovery against the liable party that the amount we actually recover bears to the total recovery.
Before accepting any settlement on your claim against a third party, you must notify us in writing of any terms or conditions offered in a settlement, and you must notify the third party of our interest in the settlement established by this provision. In the event of a trial or arbitration, you must make a claim against, or otherwise pursue recovery from third-parties payments we have made on your behalf, and give us reasonable notice in advance of the trial or arbitration proceeding (see Notices). You must also cooperate fully with us in recovering amounts paid by us on your behalf. If you retain an attorney or other agent to represent you in the matter, you must require your attorney or agent to reimburse us directly from the settlement or recovery. If you fail to cooperate fully with us in the recovery of the payments we have paid on your behalf, you are responsible for reimbursing us for payments we have made on your behalf.
You agree, if requested, to hold in trust and execute a trust agreement in the full amount of payments we made on your behalf from any recovery you obtain from any third-party until such time as we have reached a final determination or settlement regarding he amount of your recovery that fully compensates your for your loss.
In WA, since I'm the single member owner of my LLC and have no employees, I'm not required to have worker's comp, but I do have the option to elect it for myself. The rates are fairly reasonable, but if my health insurance (an individual Premera plan) will cover me, I don't immediately see the need. So the question is, "if I'm injured on the job, will my health plan cover me?"
Here are two areas from my benefits booklet, under the headings "Individual Medical Plan" and "Third Party Liability/Subrogation."
First they referenced the section on subrogation, explaining that basically they would 'cover a work-related injury as long as there was no other coverage available, or as long as I didn't seek damages from another possibly-liable party.' I will paste the section on subrogation at the end of the post.
Then I found this section:
Individual Medical Plan:
This contract is sold and issued in Washington State as an individual medical plan. It is not issued for use as an employer-sponsored or group health plan. Premera specifically disclaims any liability for state or federal group plan requirements.
This contract does not replace, affect, or supplement any state or federal requirement for worker’s compensation, employer’s liability, or similar insurance. When an employer is required by law to provide or has the option to provide worker’s compensation or similar insurance and does not provide such coverage for its employees, the benefits available under this plan will not be provided for conditions arising out of the course of employment which are or would be covered by such insurance.
The agent on the phone told me that this section is essentially stating that it is a health plan only, and would not offer worker's comp benefits like lost wages, etc. But that's where I'm not convinced. As an LLC owner with no employees, how do I fit into that second paragraph? Could I technically be an employer and/or an employee? And while I'm not required to provide worker's comp, I do have the option. I can imagine a scenario where my claim gets denied because someone determines that I had the option to elect workers comp but didn't, given that paragraph.
The agent's summary was, "as long as there was no L&I claim, you would be covered." That sounds great and fair enough, but still I'm just not sure how thoroughly I need to cover my butt here. Any input would be greatly appreciated...thank you for reading! Section on subrogation follows. -afflab
THIRD PARTY LIABILITY (SUBROGATION)
If we make claims payment on your behalf for injury or illness for which another party is liable, or for which uninsured/underinsured motorist (UIM) or personal injury protection (PIP) insurance exists, we will be subrogated to any rights that you may have to recover compensation or damages from that liable party related to the injury or illness, and we would be entitled to be repaid for payments we made on your behalf out of any recovery that you obtain from that liable party after you have been fully compensated for your loss. The liable party is also known as the "third party" because it is a party other than you or us. This party includes a UIM carrier because it stands in the shoes of a third party tortfeasor and because we exclude coverage for such benefits.
Definitions The following terms have specific meanings in this contract:
• Subrogation means we may collect directly from third parties or from proceeds of your recovery from third parties to the extent we have paid on your behalf for illnesses or injury caused by the third party and you have been fully compensated for your loss.
• Reimbursement means that you are obligated under the contract to repay any monies advanced by us from amounts you have received on your claim after you have been fully compensated for your loss.
• Restitution means all equitable rights of recovery that we have to the monies advanced under your plan. Because we have paid for your illness or injuries, we are entitled to recover those expenses from any responsible third-party once you have been fully compensated for your loss.
To the fullest extent permitted by law, we are entitled to the proceeds of any settlement or judgment that results in a recovery from a third party, up to the amount of payments we have made on your behalf after you have been fully compensated for your loss. Our right to recover exists regardless of whether it is based on subrogation, reimbursement or restitution. In recovering payments made on your behalf, we may at our election hire our own attorney to prosecute a subrogation claim for recovery of payments we have made on your behalf directly from third-parties, or be represented by your attorney prosecuting a claim on your behalf. Our right to prosecute a subrogation claim against third-parties is not contingent upon whether or not you pursue the party at fault for any recovery. Our right of recovery is not subject to reduction for attorney's fees and costs under the "common fund" or any other doctrine. Notwithstanding such right, if you recover from a third party and we may share in the recovery, we will pay our share of the legal expenses. Our share is that percentage of the legal expenses necessary to secure a recovery against the liable party that the amount we actually recover bears to the total recovery.
Before accepting any settlement on your claim against a third party, you must notify us in writing of any terms or conditions offered in a settlement, and you must notify the third party of our interest in the settlement established by this provision. In the event of a trial or arbitration, you must make a claim against, or otherwise pursue recovery from third-parties payments we have made on your behalf, and give us reasonable notice in advance of the trial or arbitration proceeding (see Notices). You must also cooperate fully with us in recovering amounts paid by us on your behalf. If you retain an attorney or other agent to represent you in the matter, you must require your attorney or agent to reimburse us directly from the settlement or recovery. If you fail to cooperate fully with us in the recovery of the payments we have paid on your behalf, you are responsible for reimbursing us for payments we have made on your behalf.
You agree, if requested, to hold in trust and execute a trust agreement in the full amount of payments we made on your behalf from any recovery you obtain from any third-party until such time as we have reached a final determination or settlement regarding he amount of your recovery that fully compensates your for your loss.
