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  1. #1
    Join Date
    Apr 2009
    Location
    North of Phx., AZ.
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    20

    Default How Much is Fair?

    I had a fusion done (L3-L4) April of 2008 I was injured lifting a rollup door in 2007 and was a Truck Driver at the time, I have pain in the tail bone area and no know what is causing it. I have VA benefits and my doctor is willing to help figure it out. The carrier has agreed to pay me a whopping $449.00 a month and allow me 2 more visits to my surgeon over the next 12 months.
    Of course I sent a letter to the ICA and told them I didn't think the after care was adequate nor did I feel the money was fair which has generated a hearing in front of "Da-Judge" so now the carrier has agreed to offer a lump sum for me to sign off and I'm trying to figure out what would be fair and reasonable. They already said no to a Mil. LOL, so if anyone out there has had any experience in this are I would appreciate the input. Thx...Wes

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,938

    Default Re: How Much is Fair?

    I'm trying to figure out what would be fair and reasonable. They already said no to a Mil. LOL, so if anyone out there has had any experience in this are I would appreciate the input.
    Well Wes, they would LOL at the 1M suggestion on settlement.

    The value of your injury is based on your impairment/loss, that is defined in a % of your whole person impairment, or scheduled loss due to the injury.
    information on PPD benefits is here...http://www.azleg.gov/FormatDocument....23&DocType=ARS
    the carrier has agreed to offer a lump sum for me to sign off and I'm trying to figure out what would be fair and reasonable.
    The value of your claim is based on the PPD indemnity, and any future medical as described by your treating physican.

    If you accept the lump sum payment, you are releasing the ER/IC from all further liability for this injury/body part.
    All additional treatment as may be necessary will be out of your pocket.
    The money you receive for FMC, should be deposited in an interest bearing account and used only for treatment to your work injury.

    There is no amount in a lump sum that you or the ER/IC would consider 'fair'...you will both feel you could do better after the agreement documents are signed and approved.
    You can find other information on compensation issues in AZ here...
    ticle 9 Payment of Compensation
    23-1061 Notice of accident; form of notice; claim for compensation; reopening; payment of compensation
    23-1061.01 Treatment by prayer or spiritual means
    23-1062 Medical, surgical, hospital benefits; commencement of compensation; method of compensation
    23-1062.01 Timely payment of medical, surgical and hospital benefit billing; content of bills; contracts between providers and carriers; exceptions; definitions
    23-1063 Apportionment of compensation
    23-1064 Presumptions of dependency; determination
    23-1065 Special fund; purposes; investment committee
    23-1066 Minor or incompetent claimant; appointment of guardian ad litem; procedure
    23-1067 Commutation of compensation to lump sum payment
    23-1068 Assignment of compensation; exemption from attachment or execution; payment to nonresident
    23-1069 Attorney's fees; payment; time limitation
    23-1070 Medical, surgical and hospital benefits provided by employer
    23-1070.01 Request for early hearing; stipulation; action of commission
    23-1071 Notice by disabled employee of absence from locality or state; failure to give notice; change of doctor
    23-1072 Autopsy in death claims; effect of refusal by claimant
    23-1073 Processing of prior claims
    http://www.azleg.gov/ArizonaRevisedS...s.asp?Title=23
    There is a lot more to consider in a lump sum payment/settlement to a comp claim than the 'big' check.

  3. #3
    Join Date
    Apr 2009
    Location
    North of Phx., AZ.
    Posts
    20

    Default Re: How Much is Fair?

    BvIA, Thanks for the input I know what you mean I had a fusion in 91 (L4-L5-S1) which took until almost 95 to finally settle but I ended up getting retrained, it healed just fine but I only got 29k in my hand and guess over the last 17yrs or so it stressed L3. The future medical shouldnt be a problem as I have VA medical and my VA doc. has ordered PT to do an evaluation.
    The IME said Im @ 15% and said I can return to working an 8hr day as long as Im able to change position every 30 minutes or so because he says Im still healing, I for some reason have pain in my tailbone area, but like I say my VA doc. is going to help me get it figure out. Obviously I cant go back to driving but they did determine I could get a job as a cashier in a self serve gas station and should be able to nock down $9.15 pr. Hr.!
    After I got thru laughing I asked them where in AZ. do they pay that and what year.
    I spoke to an attorney a few weeks ago that felt I should just handle it myself but if he took it he would probably be able to get me about $600 for 5yrs. And because they already agreed to give me $449 he would only ask for 25% of anything over the 449 but if I got a lump sum he would need 25% of that and said he might be able to get around 65K. Its my understanding that if take a monthly amount for Xyrs. They would reevaluate m every yr. and they decided I was @ 100% they could stop my beny?
    ThxWes

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,938

    Default Re: How Much is Fair?

    You should begin thinking about how any settlement is going to be paid out.. http://search.cms.hhs.gov/search?q=c...ntend&oe=UTF-8. There is a lot more to consider vs a lump sum payment. As you are considering/intending on using your VA/TriCare benefits...you may be required to use a setaside arrangement on any money you receive for the medical treatment you need in the future.

    Group Health Plan (GHP) Insurance, Managed Care Plan, and Veterans' Administration (VA) Coverage
    (Ref: 7/11/05 Memo Q8)
    In a WC settlement, a WCMSA is recommended where the claimant is covered under a GHP or a managed care plan or has coverage through the VA. A WCMSA is still appropriate because such other health insurance or health service could in the future be canceled or reduced, or the injured individual may elect not to take advantage of such services. It is important to remember that workers' compensation is always primary to Medicare and many other types of health insurance coverage for expenses related to the WC claim or settlement.
    As the new reporting rules take affect July 1st, 2009, all claims that include medical treatment must be reported to CMS/Medicare, and will be tracked. When you become Medicare eligible, you must prove you have exhausted the money you receive now for FMC before Medicare will provide benefits.

    Even if you access your VA entitlemets... you could/should use the FMC money to treat the industrial injury before using/allowing VA to pay for treatment to the injury.
    The VA/Tricare has NO liablity to treat your work related injury, either the ER/IC or you out of pocket are liable for that treatment cost.

    If you are to receive compensation for medical treatment you may need if the future, and allow another party to pay, it would be ''double dipping'' and could be illegal, as well as fraud.

  5. #5
    Join Date
    Apr 2009
    Location
    North of Phx., AZ.
    Posts
    20

    Default Re: How Much is Fair?

    Good Grief BvIA, just when I thought I had it figured out as much as I hate to give what little I may be eligible for it might be prudent to hire legal representation to make sure I don't end up in the slammer! What is your fee .
    Is there any way to specify any money I receive is strictly compensation for lost wages. Because there IME said I am 15% disabled, the pain in my tailbone would go away in time and therefore no longer able to drive truck.
    Again thank you fore the input it is really opening my eyesWes

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
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    Default Re: How Much is Fair?

    my wife was awarded a settlement because of an injury and we just learned that half of it will be put in a msa account. we already used part of the other half of the settlement to pay for her surgery. i was told by are representative in our case to medicare that we should get reimbursed that money.
    No...and depending on the total amount of the settlement, you may have to submit the setaside proposal to CMS/Medicare for a review.

    There are always specifics to any claim, and subsequent settlement...changing the language around to suit your needs is possible to a point...shifting liability for the medical treatment from your ER/IC, or you out of pocket, to the VA or Medicare isn't one of those options.
    I hate to give what little I may be eligible for it might be prudent to hire legal representation to make sure I don't end up in the slammer!
    I doubt any jail time is pending... but it's always a good idea to consult with an attorney when you are not sure what you are doing yourself...kinda like doing surgery on your own tailbone... difficult to see...(?)

  7. #7
    Join Date
    Apr 2009
    Location
    North of Phx., AZ.
    Posts
    20

    Default Re: How Much is Fair?

    I see what you mean, I have an appoinmnt with an attorney tomorrow and a couple have emailed me lettingmt know they are willing to take it. So will see what he says tomorrow and go from there. Hate to put out the 25+% but it's better than ending my ignorance they usually don't buy that. Thank again I'll let you and the community know how it goes...Wes

  8. #8
    Join Date
    Apr 2009
    Location
    North of Phx., AZ.
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    Default Re: How Much is Fair?

    sked the Attorney about the "double dipping" if I accept a lump sum and use the VA for after care and he said it would not be a problem also ased about being forced to put 1/2 of the lump sum into an account for after care, said he never heard of such a thing. Maybe in your wife case it was because she hadn't had surgery and my is a year past and I am considered stationary. Well will wait and see if they offer my anything or maybe they want to go infront ofthe judge and let him/her decide?...Wes

  9. #9
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: How Much is Fair?

    sked the Attorney about the "double dipping" if I accept a lump sum and use the VA for after care and he said it would not be a problem
    Ask the atty to explain to you his defination of double dipping. HOW can you be compensated for somthing/medical treatment you may need in the future, and then allow another party to pay for that same treatment? You would be compensated twice for the same 'loss'...

    Also tell your attorney to read the information provided by CMS/Medicare...
    In a WC settlement, a WCMSA is recommended where the claimant is covered under a GHP or a managed care plan or has coverage through the VA. A WCMSA is still appropriate because such other health insurance or health service could in the future be canceled or reduced, or the injured individual may elect not to take advantage of such services. It is important to remember that workers' compensation is always primary to Medicare and many other types of health insurance coverage for expenses related to the WC claim or settlement.
    also ased about being forced to put 1/2 of the lump sum into an account for after care, said he never heard of such a thing.
    It's not 'half' of your settlement. IF you are required to have a WCMSA proposal submitted to CMS?Medicare, they will tell you IF, and how much money is required to be provided for the setaside account.

    If your attorney isn't familiar with the federal laws, he should begin reading the mandates, and/or you should seek new counsel.
    Also, request this attorneys mal-practice insurance provider.
    IF the parties do not take the steps to protect Medicare interests there could be fines up to $1000/DAY...not something you want to fool around with.
    Maybe in your wife case it was because she hadn't had surgery and my is a year past and I am considered stationary
    That has nothing to do with this...

  10. #10
    Join Date
    Apr 2009
    Location
    North of Phx., AZ.
    Posts
    20

    Default Re: How Much is Fair?

    Again thanks for the input and I will pass it on to my attorney but from what I read:
    The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; OR
    The claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.
    I'm not on Medicare and If only it would be greater that 250k...Wes

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