Results 1 to 8 of 8
  1. #1
    Join Date
    Apr 2010
    Posts
    11

    Default After Settlement of Workers Comp, What Does Personal Health Insurance Cover

    My workers compensation claim was made in the State of: California

    I have been offered a C and R from the IC. My attorney has not been able to confirm with 100 pcnt accuracy that my personal health insurance would cover me completely if/when I need future medical, which I will. I am really reluctant to settle this way, unless I can get a guarantee that they will cover me. It strikes me as odd that she does not have this information readily available. Surely others have asked. My coverage is with a HMO that has locations in a few states only..not sure if I can mention their name here or not. While I need the monies, I do not want to be left without coverage.

    Thank you for advising me.

  2. #2
    Join Date
    Jan 2010
    Posts
    130

    Default Re: Settlement/Personal Health Insurance

    Hi Trvlpro! If I were you I would read more posts on the subject. Yes your attorney should know the answer to that question. I don't have a degree in law but from reading all the information on this site I think that you would have to have a medical set aside. Why would your personal insurance be paying for care that was covered by w/c. If you need future care then I would think that you would need a medical set aside to help you with that. Again I am no attorney and I am sure that others will post to help you. I would make sure you understand everything before setting for the money. It's nice to end the nightmare and get some of the money in the form of a settlement but it's just that I think, a settlement to end the case medical and all.
    Have a good holiday!
    Puppet

  3. #3
    Join Date
    Aug 2007
    Location
    Southern Illinois
    Posts
    93

    Default Re: After Settlement of Workers Comp, What Does Personal Health Insurance Cover

    Puppet what would happen if you, lets say fell on the part of body that you settled on and made the condition worse? Would private health care cover this?

  4. #4
    Join Date
    Jan 2010
    Posts
    130

    Default Re: After Settlement of Workers Comp, What Does Personal Health Insurance Cover

    Oh Dear God If that was ever going to happen to an i/w that would be me. If it wasn't for bad luck I wouldn't have any.

    If the case is closed i'm sure if it was a new injury the personal insurance company would pay it.


    Let's hope that don't happen!
    Puppet
    Last edited by Puppet to wc Doctors; 04-04-2010 at 08:39 AM. Reason: spelling

  5. #5
    Join Date
    Feb 2010
    Location
    Midwest US
    Posts
    44

    Default Re: After Settlement of Workers Comp, What Does Personal Health Insurance Cover

    My injury is a lung injury from over 15 yrs ago and if I would have settled back in the late 90's, I would be in trouble as just in the last 2 years my medical bills have been over $350,000. My lung condition has worsened and I am now on oxygen. I have been hospitalized 2x for lung infections and each hospital stay was 2 weeks. The drugs I take for my lungs has caused my bones to die and I have had bilateral hip replacement, knee replacement and wrist surgery. The steroids have also caused cataracts in both of my eyes so surgery is in the future for this condition. I would have never imagined all of these problems back when my lung injury occurred in the mid 90's. The wc carrier could have saved major bucks if they would have settled with me years ago. The only offer I had was for $60,000 and my attorney said, "NO" and he advised me that my lungs would not be covered by other insurance and while that amount of money seemed like a lot back in the 90's, it would be a drop in the bucket as far as future medical costs. I look back now and am so glad that he opened my eyes as I was thinking that I could get out of debt and be even. When you go without money for so long, that settlement can seem like a dream...and then reality happens. Be cautious and talk about leaving the medical open. I am so thankful that I did, even though it was tough going and still is. I never settled for any amount of money and am still fighting for my rights.
    Antonia

  6. #6
    Join Date
    Jan 2010
    Posts
    130

    Default Re: After Settlement of Workers Comp, What Does Personal Health Insurance Cover

    Well put antonia! I often read posts that ask about settlements but forget to mention about the future medical. It's sad how w/c pays such a fraction of what you make. They put you threw the ringer physically and mentally,lose your house,car, bills pile up so you end up in bankruptcy. Then when you can't take anymore and nothing left they dangle a little settlement at you. Most jump at it to dig there way out while others just don't want to deal with w/c anymore. My attorney also said that my privet insurance would not pay for anything after a settlement. So we must do a MSA. My injury hurt one part of my body that effected all the others. So it's my whole body that suffers. New year and new health care sure hope things change for the i/w. But for now its CYA.
    Puppet

  7. #7
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,018

    Default Re: After Settlement of Workers Comp, What Does Personal Health Insurance Cover

    Your AA doesn't have the answer because s/he doesnt' deal with health coverage issues. It would be the rare situation you would find yourself in a position to sue your private pay carrier.

    WC is about liability... your ER/carrier are liable for treatment to your injury. The money in a future medical settlement is not a part of the award/indemnity for suffering the injury, or resulting PD/impairment... if you did not need FMC, you wouldn't receive the money in the first place.
    SO... when you sell your FMC/future medical care benefits, you are accepting liability yourself..out of your pocket. Your private pay carrier does not accept liability for treatment to your injury, because you are not the party holding the initial liability.
    When you accept money in a FMC settlement, you pay for treatment with that money...when its gone, you pay with your own. To allow a GHP/group health plan to pay would be double dipping, and potentially fraud agains the carrier.

    The law says you must take Medicare interests into consideration when closing out the medical in a comp claim. It does not say you must have a setaside arrangement, but it is recommended that you have a seperate account to ensure the amount you receive for FMC is used only for treatment to your injury. When you become Medicare eligible you will have to prove all of that money has been spent on your injury before Medicare will begin to pay.
    Use of WC Settlement Funds Prior to Medicare Entitlement
    (Ref: 7/11/05 Memo Q3)
    For claimants who are not yet Medicare beneficiaries and for whom CMS has reviewed a Workers' Compensation Medicare Set-aside Arrangement (WCMSA), the WCMSA may be used prior to becoming a beneficiary because the amount was priced based on the date of the expected settlement. Use of the WCMSA is limited to services that are related to the workers' compensation (WC) claim or settlement and that would be covered by Medicare if the claimant were a Medicare beneficiary. The same three requirements that Medicare beneficiaries follow for reporting and administration are to be used in the above cases. The CMS will not pay for any expenses related to the WC injury, illness/disease until a self-attestation document or a full accounting of all monies expended from the WCMSA are sent to the lead contractor upon Medicare entitlement. At that time, the lead contractor will adjust the WCMSA record to reflect the expenses paid prior to entitlement. Even if there is no CMS-approved WCMSA, any funds from a WC settlement attributable to future medicals that are remaining at the time a claimant becomes a Medicare beneficiary must be used for Medicare-covered services related to the WC claim or settlement until such funds are exhausted. Only then will CMS pay for Medicare-covered services related to the WC claim or settlement.
    The Medicare Secondary Payor Act is here http://www.medicareapproval.com/42usc1395y.htm

    There have been a lot of threads on these boards regarding closure of the medical benefits in a comp claim, and the potential need for a MSA/setaside arrangement.
    It would be extremely important that you are fully informed, and understand the ramifications of accepting a C&R in your claim.

    More on Medicare issues is here http://www.cms.gov/WorkersCompAgency...atedtopics.asp

    You should NOT.. repeat, NOT enter into any negotiations to settle your claim until a SSA/CMS release of information has been signed by you, and the potential need for a setaside arrangement has been addressed.
    Whether it's a formal WCMedicare Setaside Arrangement, or a simple Medical Setaside Arrangement, two very distinct accounts... should be determined first.

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,018

    Default Re: Thank You to one and all/Settlement Info

    I know it is also possible to have FMC with a small settlement paid regularly, in small amounts. Anyone done that?
    Depends on your rating.
    70%+, you are eligible for a "life pension", peanuts...but better than the alternative...zero.
    100% PD, and you are paid the life pension at the TTD rate on your DOI.
    DOI post 01/01/2003 are eligible for COLA/cost of living adj each Jan 1st.
    Access to medical remains open based on ACOEM/MTUS treatment guides, and UR process.

Similar Threads

  1. Work Comp. Settlement or Health Insurance
    By paperbackpage@msn.com in forum Minnesota
    Replies: 1
    Last Post: 07-06-2009, 04:49 AM
  2. Replies: 3
    Last Post: 07-06-2009, 03:41 AM
  3. Workers Comp Insurance for Personal Caregiver
    By renegade_0503 in forum Employment
    Replies: 2
    Last Post: 06-13-2009, 06:03 AM
  4. Replies: 1
    Last Post: 09-04-2007, 03:57 PM
  5. Workers Comp Won't Cover Knee Injury
    By MMD in forum Kansas
    Replies: 2
    Last Post: 05-08-2007, 01:24 PM

Bookmarks

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
 


Find a Lawyer