Worker's comp COB

Priority Health, like most other health plans, specifically excludes from coverage any claims which are covered under any Workers' Compensation laws and/or loss due to work-related injury or sickness.

Coverage for a Workers' Compensation injury or sickness starts at the onset of the disabling condition and lasts until the condition has subsided or the claimant has accepted a settlement.

Identifying work-related injury/sickness

Priority Health will assume that a condition is work-related when we receive information from any source, such as:

  • Physician, either verbal (with internal documentation) or written
  • Claimant, either verbal (with internal documentation) or written
  • Employer
  • Other sources

Claims considered Workers' Compensation

Priority Health is not responsible for:

  • Claims for work-related injury or sickness care
  • Claims denied by a Workers' Compensation carrier as a result of the claimant not following appropriate procedures, such as reporting the incident to the employers
  • Claims which the claimant refuses to report or file with the employer's Workers' Compensation carrier
  • Claims incurred after a Workers' Compensation settlement but related to the original work-related injury or sickness
  • Claims in dispute by the Workers' Compensation carrier. Claims will only be reconsidered under Priority Health when a final resolution has been reached and only when we receive a copy of the Department of Labor Opinion/Order stating the claim has been denied.