Many health insurance policies contain subrogation clauses. This means a person’s health insurance company can recover any money that it paid to the plaintiff or their medical providers from the person that caused the plaintiff’s injury (usually the defendant’s insurance company).
Capitated plans are unusual because the capitated amount is a set fee paid by a health insurer to a medical provider for each person in the network, regardless of the exact services provided, or even no services provided.
In California, Civil Code 3040 explains how these two concepts work together. If a health insurance company pays a hospital or medical provider on a capitated basis, then for subrogation purposes, when the company attempts to recover medical payments that it made on behalf to the plaintiff, the health insurer is limited to recovering 80% of any usual charge by medical providers on a non-capitated basis. There is also a limit of the percentage of the total recovery that can be obtained in subrogation.
Contact me to discuss more. Brett@brettpetersonlaw.com