California Worker's Compensation - Help For Injured California Workers

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  1. #1
    Join Date
    Apr 2010
    Posts
    19

    Default How to Get What's Best for My Future Out of Workers Comp

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

    I INJURED MY KNEES 9 YEARS AGO AT WORK. RIGHT KNEE HAD TOTAL KNEE
    REPLACED IN 2008 AND CONTINUE WITH EXTREME PAIN.MOBILITY IS LIMITED ON RIGHT KNEE.THE LEFT KNEE IS STILL IN PAIN.

    I HAD ONE SURGERY ON LEFT KNEE AND ABOUT 8 ON RIGHT KNEE INCLUDING A HALF KNEE REPLACEMENT AND A TOTAL KNEE REPLACEMENT WHICH RESULTED IN EXTRA PAIN.

    BOTH MY SHOULDERS ARE ALSO IN PAIN.I WALK WITH A CANE TO SUPPORT MY SELF.

    I HAD AN AME DONE AND THE DOCTOR PUT ME IN A TOTAL BODY DISABILITY OF 80 PERCENT.

    I AM HAVING TROUBLE, HAVING THE INSURANCE AUTHORIZE MY MEDICATIONS AND THEY TELL THE DOCTOR WHAT THEY WILL ONLY AUTHORIZE AND THEY STILL DON'T AUTHORIZE IT.

    THEY SENT TO GET MY MSA BECAUSE THEY WANT TO SETTLE BUT MY ATTORNEY SAYS MY CASE IS WORTH ABOUT 120 THOUSAND DOLLARS FOR INJURY ,PLUS 80 THOUSAND FOR MY LIFETIME PENSION PLUS WHAT EVER THE MEDICAL SET ASIDE SAYS.
    I FIGURE IF I SETTLE I CAN GET MY KNEES FIXED FASTER WITH MY WIFES FAMILY MEDICAL INSURANCE OR PAY WITH THE SETTLEMENT.
    IS THIS REASONABLE? AND WHAT SHOULD I EXPECT FROM MY MSA?
    IS THERE ANYWHERE I CAN MAKE SURE THE AMOUNT IS RIGHT FOR MY SETTLEMENT?
    CAN I USE MY PERSONAL INSURANCE FOR MY FUTURE MEDICAL?

    HOPE I CAN GET SOME HELP
    THANK YOU FOR THE HELP

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    IF you were to cash out the medical in your claim, FMC, there would be allocations to WCMSA, and non Medicare money. You use the MSA money ONLY for that treatment/services Medicare would normally be responsible for. No other services can be paid from the setaside arrangement.

    As such, you cannot use your wifes health coverage, you would be paid for your future medical in cash. Any other coverage paying would be double dipping.

    There is no place to go for a determination whether or not what you receive is adequate. All claims are settled based on the merits of the claim. Settlement like this is a C&R, you are agreeing to release the ER/IC from all liability to your injury, and pay out of your pocket.
    MY ATTORNEY SAYS MY CASE IS WORTH ABOUT 120 THOUSAND DOLLARS FOR INJURY ,PLUS 80 THOUSAND FOR MY LIFETIME PENSION PLUS WHAT EVER THE MEDICAL SET ASIDE SAYS.
    120K is the remaining indemnity due...? How did he come up with 80K for the life pension...? Curious.
    The MSA should not be the full value of the FMC/medical... you will have out of pocket costs once the MSA money is exhausted.
    I AM HAVING TROUBLE, HAVING THE INSURANCE AUTHORIZE MY MEDICATIONS AND THEY TELL THE DOCTOR WHAT THEY WILL ONLY AUTHORIZE AND THEY STILL DON'T AUTHORIZE IT.
    The responsibility for getting a treatment request through the UR process is with your PTP. After that, still denied, you go back to the AME. If the CA still denies treatment/medication.. you go to court. Penalties and sanctions may be due.

    There are LOTS of threads/posts here that discuss your situation. Do some research under "Disability Benefits" forum... you find answers to many of your questions there.

    Then come back, to the California forum would be best, and post your specific questions there.
    Please use upper/lower case when you type...easier to read. THX..

  3. #3
    Join Date
    Apr 2010
    Posts
    19

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    Isn't it not double dipping if your paying for the coverage with that same money and the deductibles and whatever is your percentage?
    That's what the attorney said.

    Now the amounts that he came up, he used a chart that he pulled out that calculates the age and the total body percentage and gives out the sell out amount at this time.
    Last edited by sgm; 07-14-2010 at 09:19 PM. Reason: added more comments

  4. #4
    Join Date
    Apr 2010
    Posts
    19

    Default Re: knees and shoulder caseTriing to Get Whats Best for My Future Out of Workers Comp

    IC try to force you to settle, by denying every treatment that you need and making your recovery into 9 years from a year or two that it should take.
    A doctor released me with my right knee in worse pain than before, and never touching my left knee and right shoulder.He had said he was going to treat all the body parts that where in the case.
    He saw that they messed up my right knee and tried to take me off pain meds, but the pain was too strong and decided to release me P/S at the two year limit and sent me to pain management.
    He told the insurance that I was addicted to pain meds.
    My primary treating psychologist sent me to a pain management doctor which started treating me for a month till he received a letter from the IC that he had to wean me off.
    The doctor was forced to stop the meds. I told the pain management doctor to stop them so that i can show the doctor that it was the pain making me take pain meds not addiction.
    In two weeks I saw him and he just gave me low dose pain meds and changed me to another pain management doctor of his liking.
    From there on every doctor I see the IC keeps pushing to get me off the meds even though my new PTP is about to schedule a right shoulder surgery and a left knee surgery. I was told by my AME, my PTP and every single doctor I see that my right knee is going to remain with regional pain syndrome and all other pains I have.
    Now they have my pain management doctor seeing me every week and giving me pain meds weekly.But they deny them so when I have money I end up paying for the meds.My doctor is trying to get me on a long lasting pain med but the insurance doesn't let use start the transition to that pain med all they do is tell here that she has to get me off the oxycodone and hydrocodone.
    They are trying to get me to settle and I figure I would be treated faster if I settle and pay for personal insurance and get treated.
    President Obama said that no insurance can reject coverage over past injuries.
    That's why I think I can do it and maybe leaning on doing it unless I see that it is not worth it.

    thank you hope to get more help.

  5. #5
    Join Date
    Apr 2010
    Posts
    19

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    Hi BvIA,
    Thanks for the help.
    I've been reading the forums

    (120K is the remaining indemnity due...? How did he come up with 80K for the life pension...? Curious.)


    what do you mean by this?

    Is there not a set amount for settlements?

    That's what he told me.That what the chart says that's what it has to be.You can't fight for more unless you have some clear proof to fight about.

    Do you think we can get more?
    By the way you guys have been explaining msa it seems you take what the cms tells you to take for f/m.

    By the way great work guys.You guys help out a lot I have learned so much from you guys.It seems that you mean, don't negotiate your future medical,take no less than what the cms tells you, that you need.
    But do you think the indemnities due and the pension can be negotiated?

    thank you hope to learn more from you guys

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    what do you mean by this?
    Is there not a set amount for settlements?
    That's what he told me.That what the chart says that's what it has to be.You can't fight for more unless you have some clear proof to fight about.
    Indemnity is not the same as life pension.
    Indemnity is paid for a predetermined number of weeks based on the PD/WPI rating.
    If you are rated at 70% or higher there would be a 'life pension' due after the PPD indemnity has been satisfied. IF there were to be a commutation of the life pension, it would be calculated on your life expectancy... probably after the PPD indemnity weeks have paid out. LP is paid at a MUCH lower rate than the PPD.

    I don't know what "clear proof" you might have to fight for more money. Like you said, indemnity is by the charts..actuall statutes.

    Do you know how many weeks PDA's/Permanent Disability Advance benefits you are due...?
    By the way you guys have been explaining msa it seems you take what the cms tells you to take for f/m.
    WCMSA is not the total of FMC you should be negotiating for. FMC is one number... in that there should be allocations for WCMSA... and non Medicare services. Once the MSA money is exhausted, and Medicare begins to pay for treatment, YOU will have out of pocket costs. W/o non-Medicare money in the FMC award, you'll use your own money for those copays/deductibles associated with your work related injury. Should NOT be the case. And, there are many services/treatment/medications Medicare does NOT normally pay for...you can't use MSA money for those items.
    It seems that you mean, don't negotiate your future medical,take no less than what the cms tells you, that you need.
    I don't believe that to ever have been the case...I would not accept FMC total as what CMS approves. Never.
    But do you think the indemnities due and the pension can be negotiated?
    No...you are not going to get more indemnity due than what the statutes provide based on your rating. And you'd probably get much less in a C&R.
    I'm not even sure you have a life pension coming... (?)

  7. #7
    Join Date
    Apr 2010
    Posts
    19

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    (No...you are not going to get more indemnity due than what the statutes provide based on your rating. And you'd probably get much less in a C&R.
    I'm not even sure you have a life pension coming... (?))


    My at

    (No...you are not going to get more indemnity due than what the statutes provide based on your rating. And you'd probably get much less in a C&R.
    I'm not even sure you have a life pension coming... (?))


    My AME was submitted to BWC for a rating and it came back at 80% and we still need my psychological part of the case.
    Your right I do get less on a C&R.
    So to settle I should look for:
    Indemnities
    Life Pension
    CMS amount for MSA
    Plus non covered medications and procedures not covered by medicare which are not included in the CMS.

    Question?
    How do I know how much I should get for non covered medications and procedures not covered by medicare which are not included in the CMS?

    Thank you BvIA you have taught me a lot.You and every body in this website .
    GOD BLESS YOU ALL

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    There is no BWC in Calif...(?) Ohio has a "BWC"...

    There is a process to determine the potential value of FMC... taking the past 2 or 3 years of treatment costs. You need a benefits printout to get those figures. Not generally something the IW could do on his/her own... and use the info in the AME report that provides the need for FMC as well as the final rating.
    at 80% and we still need my psychological part of the case.
    If you are referring to the DEU/Disability Evaluation Unit, ALL ratable medical reports should be sumbitted, that would produce a final PD/WPI rating. There are no additional or reratings later on when any other issues arise, ie the psych. If you don't have a final rating at this point, you are not ready to C&R this claim.
    They are trying to get me to settle and I figure I would be treated faster if I settle and pay for personal insurance and get treated.
    President Obama said that no insurance can reject coverage over past injuries.
    That's why I think I can do it and maybe leaning on doing it unless I see that it is not worth it.
    Forget about Obamacare and "pre exsisitng'' conditions, That does not affect anything with WC. WC is about liability of the ER for injury in the work place, WC is not health insurance.

    And yes, It IS double dipping when you accept money from one party to pay for FMC and then let another party pay the bills... that could be fraud.
    So to settle I should look for:
    Indemnities
    Life Pension
    CMS amount for MSA
    Plus non covered medications and procedures not covered by medicare which are not included in the CMS.
    The carrier isn't going to pay out cash to you for medications you are taking now, where there is no indication you would be on those for life. You said they are instructing the PTP to wean you now... which is appropriate to any claim. Long term pain medications are not useful in determining what your actual pain level is. You have to wean so the Dr can determine what other possibly OTC, medication would be effective.

    On top of all this "thinking" and questions, you cannot force the carrier to C&R the claim anyway. If the WCMSA is too costly... they simply will withdraw the offer to settle the claim. I know this to be a fact, I've had it happen more than once in my own claim.

  9. #9
    Join Date
    Apr 2010
    Posts
    19

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    Hi BvIA,

    You say you can't force IC to C&R, well I'm not trying to force them.They are the ones that are trying to move all the settlement talks.Thats what the attorney told me.We went to trial at the BWC offices, that by the way there is one in San Diego and the judge ordered to have the AME report rated and came back at 80%.
    The attorney says we'll just wait for our next trial which is next month, the IC should have by that time the MSA amount.
    I'm not eager to settle but if I get a good deal I would do it.I can always get any doctor treatment in Mexico, faster and cheaper if I settled.
    Wouldn't mind getting some money to invest instead of giving them the time to use my money and put it to work for their profit and I not getting any profit out of it myself.
    All the settlement talk would have to convince me that it is worth it.
    My injury by the way the doctors tell me. I'll have this pain for the rest of my life. I'm not planning to sell out my medical with out thinking it through and figuring out how I can make that money last forever for my medical needs and my family needs.

    I guess I'll know a little more, by the trial date next month and hopefully everything works out fine.

    My new Dr. says we just have to find the meds that will work without taking big amounts.Probably use some long lasting morphine with some small amouts of oxycodone.
    Well we'll see it feels like things are starting to get shape and I'm starting to understand how to cope with it.I guess it's just the bad depression days that really put me in doubt,but hopefully with gods help I'll get through them.

    thanks again for the knowledge hope to continue picking your brain for more knowledge.

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Triing to Get Whats Best for My Future Out of Workers Comp

    When you have a cash payment/C&R to close a claim, and a WCMSA is included in the FMC allotations...you can use the MSA money ONLY for what Medicare would normally be responsible for.... if you treat outside the country/Mexico...you'd have to pay out of your pocket, not use the MSA money cuz Medicare does not pay for that treatment in Mexico or any other foreign country. If you were to take the indemnity and invest it, and FMC were to be in a WCMSA, you wouldn't be left with much cash to pay for treatment in Mexico...(unless you have significant other income...which you may)
    Wouldn't mind getting some money to invest instead of giving them the time to use my money and put it to work for their profit and I not getting any profit out of it myself.
    It isn't really "your money"... it is "your" weekly benefit. When you die, the claim dies too. There is no estate value in a WC indemnity award. You are guarantee the weekly payments until the indemnity and/or life pension is satisfied. Unless you die of complication related to your injury, your heirs/dependents would receive nothing.

    As to investing...What you do with your indemnity money and/or FMC money not in a WCMSA, is of course up to you...BUT, you cannot self invest that money, and replace the weekly benefit amount you currently receive. When you take taxes both state/federal and inflation into consideration, that money won't earn enough to replace the weekly PDA's.
    You say you can't force IC to C&R, well I'm not trying to force them.They are the ones that are trying to move all the settlement talks.Thats what the attorney told me.
    I'm not saying you are trying to force a C&R... but when the MSA comes back from CMS with the approval...the carrier is free to walk away from any offer on the table...if they don't like those numbers, that's likely to be the result. At that point, youu can't force anything to a lump sum payment.
    the IC should have by that time the MSA amount.
    YOU should/must receive a notice from CMS/Medicare regarding the WCMSA status. I wouldn't move forward with any negotiation w/o that letter.

    As I said before, there is no "BWC" in Calif... our courts are the "WCAB", Workers Compensation Appeals Board. That is the court of jurisdiction over all WC claims.

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