My son broke his finger in school yesterday...Question about insurance payment

[mrsmiller]

Yesterday during lunch time a boy threw a football at my son's hand on purpose this is a troublemaker kid and he thought that it was funny, my son told the person that was in charge of the school yard and he told my son that he was OK and there was no need to see the nurse.

When my son got home from school he told me what happened and show me his hand, His pinkie finger was a little swollen and red, nothing at the time to be alarm I called his pediatrician and he told me to put ice and give him Motrin.

Today his hand was really swollen and he was in a lot of pain, so I took him to the ER(called his dr first) and his finger is broken in two places, the doctor did not put in a cast because of the swelling, he wants to wait till Monday, and take more x rays and put the cast, but also mentioned something called open reduction/fixation(????)so we are looking to a lot of appointments and doctor's visits. I know that the out of pocket expenses will be high

I am upset because this was no accident this was done on purpose and because I was never contacted by the school to let me know what happened (my son and his friends told the person in charge of the school yard what happened)

I am not looking for a lawsuit, but would like to know if the school will be the one responsible for the medical bills, I have not contacted the insurance (HMO)yet as I am waiting for the plastic surgeon to tell us Monday what we are going to do, and I am worried that the insurance will denied payment on the fact that It happened in school.

Any of you have any idea on how to handle this, any advise?

Thank you so much

It's beginning to look like 2008 is not going to be a good year for us


Linnette

 

[clh2]

In my school district, they make it pretty clear that the school is not responsible for any medical bills, and that if you don't have insurance, there is a kids-only insurance you can sign up for - don't know how much this is, or what it covers.

Now - if it was an accident - why would the school be responsible anyway. Not to stir the pot or anything, why wouldn't the family of the kid be responsible?

 

[CarolA]

I don't think the school is going to be responsible. And while it's "on purpose" the truth is that this kind of injury could happen on the playground at any time. Your insurance will pay.

Now, my only other suggestion would be to not panic over what the ER doc told you. They are NOT orthopedics which is where I would go next. (I broke my pinkie in 8th grade and they put a cast on my hand and I was done. Nothing else and it works just fine almost 40 years later)

(And why is your first appt with a plastic surgeon?)

 

[mrsmiller]

We have private insurance(HMO) the reason I asked about if the school is resposible is because when my son needed speech therapy the insurance will not pay for them because the school had to provide the service( I know it is not the same thing) I really a pain the way HMO are, and I just wanted to make sure before I give them a call ... I do understand that accidents will happen, and is ok if we have to pay,
why a plastic surgeon? I do not know when I went to the ER the drs called him and he was the one that saw my son and told me that I have to see him Monday but I will call his Ped tomorrow to find out ...
Thank you all
Linnette

 

[Alphabetsoup]

Actually...the school IS negligent in this case. They should have at the very least made a note of the incedent, put ice on it and filed an incident report. The fact that they did not and the finger is broken, does come back to them. Both my brother and sister-in-law are teachers and they have very strict rules about reporting this kind of incident for just this type of situation.

Are they (the school or the teacher) liable for medical expenses, no. However, if this was done 'on purpose', and has caused injury, the school MUST react by at least dealing with the child that caused the injury in the first place. However, proving that it was done on purpose may be difficult unless the other child has a documented history of potentially harmful behaviour.

 

[angeleigh]

When a child gets hurt at my children's school our personal insurance is primary and the school insurance is secondary. They will pay what is not covered but all bills must first be submitted to personal insurance. It may be different at your sons school. I would contact the school.

 

[HelenePA]

I dont know anything about schools and insurance BUT I did break my pinky once! I had to have pins put in. It was pretty easy I was put under, the dr put 2 pins in my hand to keep the pinky from sliding down (OUCH) and healing all werid, I was then put in a cast for 6 wks (I think) the part that sucked BAD was the pins were actually sticking out thru my skin and catching on the fuzzy stuff inside the cast OMG Talk about PAIN!!! I think it took about 30 min to do? my dr did it on his "lunch break". Removal was done while I was awake. I had a local put in my finger, small cut (VERY SMALL) and they pull them out, I felt NOTHING. I hope your son doesn't need this done but if he does its not that bad.

 

[undertheradar]

Use your own insurance and don't press the issue. Based upon the original post, there would be coverage and it reads as if you are looking for someone to cover your out of pocket expense? You have one side of the incident and there is always another side to it. How exactly do you(not your son) know that it was intentional?

 

[ceecee]

Your insurance should not have a problem paying it, HMO or not. The school is in no way responsible. Maybe you could sue the other kid's parents insurance for your out of pocket, but you would have to prove it was intentional, I doubt he meant to break a finger by throwing a football. Why does a plastic surgeon need to be called in or do you mean an ortho.?

 

[bumbershoot]

Twice now when we've had claims for DS, we've gotten a letter a couple months later from insurance asking if anyone else could have been at fault. One time was for a burn, they wanted to know if someone else was at fault or if it was just an accident. I said it was just an accident and sent it back in.

I figure they are trying to see if they can go after someone else for the costs they put out for his ER visit.

So you might get one of those. But probably by the time you do you'll just figure that "schoolyard accident with other child", and I'm sure they'll be done with it.

 

[daughtersrus]

My experience is that the school will not be responsible. My DD is disabled. She was in a self-contained special education classroom. My DD's leg was broken by her 1 on 1 aid (that wasn't properly trained by the district). She required surgery to have two rods inserted into her femur to repair the spiral break.

Our insurance refused to cover the costs since they determined someone else to be at fault. The school district refused to pay for the bills as well because in IL, they are protected through the "tort immunity act". You need to prove that they willful intended to hurt the child or that they knew that their action or inaction would harm the child. So, we were left with $30,000+ in medical expenses.

To make a very long story short, our insurance (through DH's union) agreed to pay for the expenses as long as we would sign a subrogation agreement. We did. We also got an attorney involved and we were able to show that they knew that they were supposed to be providing training to the aid and didn't.

We did settle the case out of court but after the attorney got his share, the insurance got their money back, the expenses were paid, our DD got the least amount out of everyone else.

Our schools also sell insurance to cover a small portion of injuries that a child may get while at school.

As for the child willfully hurting your child, you may have a case with his parents. I know that our homeowners insurance covers damages that our children may cause.

I wish you the best of luck!

 

[It's A Happy Day]

I took him to the ER(called his dr first) and his finger is broken in two places, the doctor did not put in a cast because of the swelling, he wants to wait till Monday, and take more x rays and put the cast, but also mentioned something called open reduction/fixation(????)so we are looking to a lot of appointments and doctor's visits. I know that the out of pocket expenses will be high

I am upset because this was no accident this was done on purpose and because I was never contacted by the school to let me know what happened (my son and his friends told the person in charge of the school yard what happened)

I am not looking for a lawsuit, but would like to know if the school will be the one responsible for the medical bills, I have not contacted the insurance (HMO)yet as I am waiting for the plastic surgeon to tell us Monday what we are going to do, and I am worried that the insurance will denied payment on the fact that It happened in school.

Any of you have any idea on how to handle this, any advise?

Thank you so much

It's beginning to look like 2008 is not going to be a good year for us


Linnette

1st I would sit your son down and have him put in writing exactly what happened. Explain that he is not in trouble but you need to know exactly what went on and make sure it is a case of the other kid really just doing this to your son or your son made a comment, hit him, whatever. Explain that this comes down to the fact that alot of $$$ is probably going to be spent and the person who caused the injury should be responsible for those costs. If he has something to do with what happened then there is nothing you can do other than to chalk it up to an accident.

I would contact the principal of the school and notify him/her of what happened. I would let them know that you have a written statement from your son and you have also documented yourself what steps have been taken since he got home on day 1 - iced, medicated, went to er, etc. Document who you spoke to and when. If it does appear that this was a situation of the other child striking out at yours then I would insist on some type of disciplinary action be taken. Yes, the school should have notified you what happened but are they responsible for the damages, I don't know. I would be more inclined to think the other childs parents would be but I do not know that answer.

As far as your HMO, you should not have a problem with them paying out on this claim. An HMO will not pay for certain things that are required to be provided to a school age child by the state/federal govt. Speech therapy is one of those things. Looking at the situation you have described above I do see the insurance possible pulling a couple other things:
#1 they may deny the ER visit as it was not technically an emergency (in their eyes, I am not saying it wasn't) and they would have wanted you to go to an urgent care center or just have the dr. set up an x-ray appt and then send you to an ortho doc. Yes, they have denied claims even when the primary physician says "go to the ER" if the insurance co. requirements do not show it was an "emergency".
#2 they may deny your appt. monday with the plastics physician which I really do not understand why you need to see him again. I would call your primary physician again and have him refer you to an orthopedic doctor. Then you will also have a referral on record which is usually required. In the least I would call the primary and have them send a referal for that appt.
#3 call your 800 number on the back of your HMO card. Let them know your son was injured and treated in the ER for a broken finger/hand and that he has to see the doctor on Monday. Do they require an auth or any prior arrangements. If you are asked to explain what happened keep it simple to "a kid threw a football surprising my son and he injured his hand."

You may not need everything in writing but it will help you IF you do need it to go after compensation or to appeal a denied claim with the insurance co. You also want something on record with the school as far as this child causing bodily harm to others to ensure he will not target your son in the future. Good luck, being a parent is always an adventure!

 

[allison443]

You said you have health insurance-when you took your son to the emergency room didn't you give them your insurance information? If not, what payment arrangements did you make with the hospital?

Also, does your health insurance policy require you to notify them if you go the ER? We don't have an HMO but if we go the ER we have to call the insurer asap, I think within 24 hours. You need to check your policy on this.

As far as your son's injury, I hope he gets better quick! I agree with other posters-you need to see an orthopedist-open reduction/internal fixation is an orthopedic surgery, not plastic surgery!

In defense of the school, even though your son told them he hurt his finger, I don't blame them for not thinking it was serious AT THE TIME. I mean, he came home later that day from school and you didn't think it was that serious either, right? It wasn't until the next day that it was so swollen you took him to the ER. Since they didn't think it was a serious injury, I wouldn't expect them to notify parents of every bump or bruise.

The school MIGHT have insurance coverage for students injured at school. However, the coverage might be secondary to your own health insurance, that is, you go through your own insurance and they cover any out of pocket expenses. My daughter's school (private school) has this and when she was injured in a school soccer game they would cover out of pocket expenses.

As for a lawsuit against the other kid, you might have a tough time proving intent-he threw the ball at your son's hand-maybe he expected him to catch it? It's different than if he threw it at your son's back or face.

Anyway, I hope everything works out and he's not in too much pain!

 

[maleficent esq.]

Most likely the school will not pay, the school and any teachers watching the children will be given sovereign immunity. (means most likely you cannot sue) your insurance should cover the incident - but not sure why you would go after the school - why not go after the child (child's parent) that threw the football. I would give it to my own insurance company and if they do not pay they can sue the other insurance company (school, other kid, whoever) you do not need the aggravation of being in a lawsuit with someone. Insurance companies are being forced to pay more claims because there are very high damage amounts if they do not. Having said all that - of course best advice contact a lawyer in your area who has some knowledge of school law, and insurance law.

 

[barkley]

my health insurer sends out a form anytime there is treatment for an injury. i have to indicate how the injury occured and they decide if they want to pursue any other parties. i have to agree to co-operate as a condition of my coverage.

that said-several years ago while i was dropping off my kids at school i slipped and came down on my knee on the edge of a curb. i ended up in the e/r and off work for several days. one of the staff had assisted me in getting off the ground so i had at least one person who was notified of the injury when it occured. i contacted the school office when i was released from the e/r and asked for their insurer's information. i contacted that company and advised them that i would be providing their info. to my insurance company and that i wanted to file an incident report 'for the record'. upshot was the school's insurer said not to bother using my private insurance-they covered everything including my lost wages

at the very least the school needs to have an incident report on file-and even if their insurance company won't cover the injury, there is nothing to prevent you from filing a claim.

 

[imsayin]

Use your own insurance and don't press the issue. Based upon the original post, there would be coverage and it reads as if you are looking for someone to cover your out of pocket expense?

Call the school, ask if they have any insurance coverage. DD broke her wrist at school (an accident during a school activity). The school had insurance that paid whatever our insurance didn't pay. I paid around $250 out of pocket that the school's insurance reimbursed me for. It doesn't matter who is at fault, if the school has the insurance, use it. I wouldn't have thought about the insurance, but the school nurse told me about it.

 

[MoniqueU]

My son fractured his hip in Dec during wresstling at his school that specifically had insurance just for sports. We are having to bill our insurance first before they will pay the rest. We were having trouble with out cobra coverage at the time and it wasn't actually in effect even though we had paid on the day of my sons accident so it has been one headache after another.

 

[mamalle]

no- they wont Im pretty sure unless you took out their supplemental insurance. as far as the school putting it on ice, etc. It doesnt surprise me. dd hurt her index finger at soccer practice. The following day it didnt look deformed but some minor swelling. I let her go to school and called late am to see how she was doing. The school nurse said it doesnt look bad at all and its not broken that she didnt need a xray. (Im a nurse too and thought well that is just your subjective opinion) she was c/o it was hurting and I took her in for a xray. she did have a fracture over the growth plate and required a thumb spica splint for 2 weeks and no sports for a month. They should have protocal in place for accidents but I think when it comes to digits compared to bones like wrists, etc they think its a minor injury. I hope your child is doing better and will not need a open reduction. Are you referred to a hand specialists not just a orthopedic doctor? good luck getting everything straighten out. We too have to notify to our insurance how accidents happen. I think that comes into play with supplemental insurance like car accidents, etc..

 

[momz]

ok, i am addressing your question about "why a plastic surgeon". The hand is a very delicate part of the body. it contains many more nerve tracts and fine tendon/ligaments than the rest of the upper extremities. Plastic surgeons are also "hand specialists". They have extensive training regarding the specific anatomy of the hand (and upper extrermity). I'm sure that an ortho specialist could deal addequately with the injury as well However, in the ER, specific specialist are "on call" for specific injuries, and often-times when it involves the hand, it is the plastic surgeon/hand specialist that takes those referrals. The ortho guys have many other injuries to cover as well. it is unfortunate that the ER doc did not explain this to you. I can see that on the surface, a referral to a "plastic surgeon" may seem odd to a person who doesn't know the extent of their training. Good luck to your son!!!!

 

[MiniGirl]

ok, i am addressing your question about "why a plastic surgeon". The hand is a very delicate part of the body. it contains many more nerve tracts and fine tendon/ligaments than the rest of the upper extremities. Plastic surgeons are also "hand specialists". They have extensive training regarding the specific anatomy of the hand (and upper extrermity). I'm sure that an ortho specialist could deal addequately with the injury as well However, in the ER, specific specialist are "on call" for specific injuries, and often-times when it involves the hand, it is the plastic surgeon/hand specialist that takes those referrals. The ortho guys have many other injuries to cover as well. it is unfortunate that the ER doc did not explain this to you. I can see that on the surface, a referral to a "plastic surgeon" may seem odd to a person who doesn't know the extent of their training. Good luck to your son!!!!

Years ago, when I had a hand injury, I was also sent to a plastic surgeon, and yes, I thought it was very odd. However, this was exactly how it was explained to me as well. It was something I never really thought about until that time.

OP, good luck with all this. I hope it all gets worked out.