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  1. #1
    Join Date
    Oct 2011
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    Default How to Calculate the Worker's Comp Settlement with 17% Pd

    I am writing on behalf of my husband.

    PART ONE:

    He was injured in September 2010, driving a limo at work. He had injury to his neck and lower back.
    We did not have a lawyer and missed a lot of things from the beginning, which is choosing a proper QME doctor, and a PTP. So, now, by the end of this case, we have "bad" reports from both of them. QME calls his injury a "lumbar disk DECEASE", PTP did not even think to have MRI of the neck at all, only lower back.
    Now, QME gave 12% WPI and released to work full duty with no significant restrictions. BUT, he also commented on the apportionment, which he believes, that my husband had 25% preexisting condition, which the last car accident he had back in 1987 and never had PD before. And the other 25% QME said was because of the latest "hit and run" rear end car accident we had in April 2011.

    So, the claim adjuster of worker's comp said in one of her letters, that she has requested the DEU rating for the QME report. Which we were waiting, and waiting, and then asking her to send us a copy of that rating, but she simply ignored request, as by e-mail, and also by phone and by mail.

    So we found out through the I&A officer that QME report was never rated and the case was not even in the system. So we requested the DEU rating and it came to 17% PD.

    She disagreed with it and asked the rater to comment on the apportionment, which he said was a legal issue and can be resolved only in court by the judge, who is going to decide, if it is inconsistent with the law.

    Now, WC claim adjuster made an offer of 15000 (minus PD already paid for 7% apportionment). We did not take it. Since then, we had hard time communicating with her, she was out of town for a months and then would not talk to us at all. We were directed to legal assistant on their behalf. He tried to bargain, said that in his 20 years work experience there, he has seen judge over rule apportionment in VERY FEW cases, so we had no chance in court, he said. Therefore, he offered us 10% PD, and 18000 settlement "out the door".

    So the QUESTION regarding WC case.
    Labor Code 4658 Section (c), do I understand it correct, that settlement should be calculated this way:

    17%PD*5(weeks)*585(2/3 of ave weekly earnings) = 49725.

    Am I correct or not in this calculation? Please help me understand.

    PART TWO:
    There is a third party involved in my husband's case. The woman was at fault, but was not cited. We were expecting to get a significant amount for pain and suffering from her insurance. Her insurance Claim adjuster took his time to decide how much money they are going to release on her policy. And came out with a very disapointing decision. They released 15000 for pain and suffering .....BUT WC had a lien for medical bills, TTD, PD, which exceeded 20000. So the third party claim adjuster suggested we divide 15000 with WC. Which of course, WC said, they will keep the whole 15000 for their lien. So now, we are basically at 0 for pain and suffering.
    We went recently to an atty. He said that this particular insurance company is know for giving a hard time in releasing insurance money. So he said there is a slight possibility they lied about actual maximum coverage for bodily injury on the insurance. They claim adjuster said he will send a declaration page to us to see the conditions of the policy. But since then he had hard time doing it, due to the system problem, he said. So tomorrow we are going to receive declaration page by fax hopefully.

    So a question.
    How else can we check the TRUE maximum bodily injury coverage on that lady policy?

    Thanks a lot for all the answer in advance, I appreciate your time to help me out.

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
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    18,017

    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    Labor Code 4658 Section (c), do I understand it correct, that settlement should be calculated this way:

    17%PD*5(weeks)*585(2/3 of ave weekly earnings) = 49725.

    Am I correct or not in this calculation? Please help me understand.
    No. PPD is paid at a lower rate... appx $230/week.
    How else can we check the TRUE maximum bodily injury coverage on that lady policy?
    From the declarations page.

    When there is a 3rd party case, the ER/IC is entitled to subrogation rights, reimbursement of benefits paid in the WC claim.
    While it's true you may be eligible for pain and suffering..that is not a coverage in the MVA policy, they pay medical and damages to the vehicle, and/or reimbursement to the WC carrier, up to the max of the policy coverage.
    You of course don't have to accept any offer to cash out either claim... the PI will always settle at some point, simply due to the policy coverages. The WC claim can remain open "for life" basically, as long as he seeks treatment. The PPD indemnity weeks paid out, leaving medical open.

    The claim can be resolved by Stipulations w/Request for Award, going to trial and a Finding w/Award & Order by judge, or cash out by C&R.

  3. #3
    Join Date
    Oct 2011
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    14

    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    BvIA is correct that the max rate for PD is lower. 17% PD: 60.5 wks * $230 = $13,915.00. BUT did your husband's employer make a return to work offer? If so, decrease by 15% ($11,827.75). No offer WITHIN 60 DAYS FROM P&S, 15% increase ($15,706.54).

    Otherwise, precisely what BvIA said.
    Has an IW hat. Has a CA hat. Wears both as suits.

  4. #4
    Join Date
    Oct 2011
    Posts
    7

    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    Thank you for replies...I understood everything you said....

    But still, what does the formula mean in Labor Code 4658? How to apply information in it to the case?
    I understand the calculation on PD payout, I have PD table, and yes, he had an offer, so they paying 15% less.

    I am trying to figure out how to calculate more or less accurately a number for settlement, so we won't take a low ball, and on other hand I don't want to be greedy and try to get every penny out of them, because we want to settle as soon as possible due to hardship.

    And also besides the declaration page, is there any other way to check them? Especially if on any reason they won't be able to send the original one by mail, but just fax it....

    Thanks.
    Last edited by NPavlova; 10-22-2011 at 10:19 AM.

  5. #5
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    Feb 2007
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    Calif
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    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    A fax copy of the declaration page is just as good as orginial for your purpose. You wouldn't get the orginial declarations page anyway, you don't own the policy. You dont have any "right" to it.

    As I said before, the 3rd party case will settle... the WC claim doesn't have to...and you cannot force a cash settlement.
    You could petition the court to commute any remaining PPD indemnity due...but as the amount is not all that much, the CA is more than likely wanting to cash this claim out.
    I am trying to figure out how to calculate more or less accurately a number for settlement, so we won't take a low ball,
    Don't expect to get the full amount of indemnity benefits due... they will take a discount.
    And a cash settlement is not an award, but "new money" for your consideration to drop the claim.

  6. #6
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    Oct 2011
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    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    Quote Quoting BvIA View Post
    A fax copy of the declaration page is just as good as orginial for your purpose. You wouldn't get the orginial declarations page anyway, you don't own the policy. You dont have any "right" to it.
    Ok, I understand that. I got the copy today. It looks strange, my female intuition tells me that there is something not right about it. =)
    Some numbers a visibly eliminated, the address of the policy holder is eliminated (which I understand privacy matters), and there is no any signature on it. I read somewhere, if there is no signature on it, it has no value in any means.
    Also in CA the minimum liability coverage is 15/30/5. They have in policy 15/30/10. I know, it is crazy question, but what kind of logic is it to cover for 10k for property damage and not cover properly for bodily injury. In other words, if they were trying to save money and cover by minimum, then why so much on property damage..?!

    So i stick to my original question: is there any other way to check what really was on that policy?


    Quote Quoting BvIA View Post
    As I said before, the 3rd party case will settle... the WC claim doesn't have to...and you cannot force a cash settlement.
    You could petition the court to commute any remaining PPD indemnity due...but as the amount is not all that much, the CA is more than likely wanting to cash this claim out.

    Don't expect to get the full amount of indemnity benefits due... they will take a discount.
    And a cash settlement is not an award, but "new money" for your consideration to drop the claim.
    I do appreciate your replies a lot. But I don't see the answer to my question. What is the LC 4658 about? How do I apply it?
    Besides, we are not forcing a cash settlement. I thought they really wanted to settle. So now it's a game about amount to settle with. Which, I am trying to get opinion on, i.e. what amount should I keep in my head to settle? (I know it's just a forum, not a lawyer appointment, but anyways, any help in that matter could be very useful). In other words, what is the WC claim value? How much is it worth do you think? Because at this late stage I am also thinking, if we really need a lawyer. I don't want to just hire somebody, and that person will not make any big difference in the case, that is close to be closed.

    Thanks a lot.

  7. #7
    Join Date
    Feb 2007
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    Calif
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    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    ). In other words, what is the WC claim value?
    Nothing. There is no claim value, the system is designed to pay weekly benefits, and medical care.
    When you cash out a claim, it's worth what you are willing to accept to agree to pay for future medical out of your pocket, and drop the claim. Yes...they do base a offer on PPD indemnity value, you have that number, but it would be discounted. There is no entitlement to medical costs... that's a "freebie".
    What is the LC 4658 about? How do I apply it?
    Which part. 4658 defines the number of weeks PPD indemnity due, job offers, SJDV/voucher etc.

    the max rate for PD is lower. 17% PD: 60.5 wks * $230 = $13,915.00. BUT did your husband's employer make a return to work offer? If so, decrease by 15% ($11,827.75). No offer WITHIN 60 DAYS FROM P&S, 15% increase ($15,706.54).

  8. #8
    Join Date
    Aug 2011
    Location
    Georgia
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    800

    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    Quote Quoting NPavlova View Post
    Some numbers a visibly eliminated, the address of the policy holder is eliminated (which I understand privacy matters), and there is no any signature on it. I read somewhere, if there is no signature on it, it has no value in any means.
    Also in CA the minimum liability coverage is 15/30/5. They have in policy 15/30/10. I know, it is crazy question, but what kind of logic is it to cover for 10k for property damage and not cover properly for bodily injury. In other words, if they were trying to save money and cover by minimum, then why so much on property damage..?!
    Since BvIA has answered your WC questions, I'll take a stab at explaining the declarations document.

    Some information is not relative to your claim, therefore, the IC is permitted to redact (remove) that information. You obviously understand the need to remove PII (personally identifiable information) such as the insured's address.

    Your assumption that the Dec Page is not valid without a signature is off. Most declarations pages are merely a summary of coverages. There is no need for a signature, since that is not the contract of insurance.

    As far as the property damage coverage being higher than the required minimum, and everything else being level, it makes perfect sense. More than 75% of vehicle collisions involve ONLY property damage claims. While most people don't increase that coverage without exponentially increasing the other coverage areas, it's less expensive to cover property damage than it is for bodily injury.

    Your "women's intuition" is reading a bit too much into this. The insurance company isn't likely to hide relative information, or to purposely mislead by altering a document. While the "agent" may try to mislead you by telephone, they aren't going to in writing. If that were to happen, the controlling Actuary would summarily tender the matter to the State Insurance Commissioner for investigation.
    Last edited by LeglEgl; 10-23-2011 at 05:44 AM.

  9. #9
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    Oct 2011
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    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    Thank you for all replies =)

  10. #10
    Join Date
    Oct 2011
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    7

    Default Re: How to Calculate the Worker's Comp Settlement with 17% Pd

    I am back....

    I keep reading the Labor Code 4658, and it says "he basic disability payment computed as follows"

    "Column 2--Number of weeks for which two-thirds of average weekly earnings allowed for each 1 percent of permanent disability"

    I don't see where it says "230 max". ( I am not talking about PD table).

    So, to update, today they offered 25,000. Whohooo!

    Also, how to object to QME report and what are the time limits to do so?

    Please somebody help me understand all that...give me some good answers...pleaseeee

    Thanks.

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