Results 1 to 10 of 10
  1. #1
    Join Date
    Dec 2009
    Posts
    6

    Cool W/C Settlement

    I know a preexisting condition can affect weather or not a W/C claim is accepted but lets say a preexisting condition exists but the IME Dr. has determined the job itself was deciding factor in the injury and worker is found to be PTD would the preexisting condition affect the settlement?

  2. #2
    Join Date
    Oct 2006
    Posts
    9,078

    Default Re: W/C Settlement

    yes. cause will allow benefits but apportionment is used to assess extent of benefits.
    the work aggravation will attach liability to the work but the underlying condition may contribute to the extent of disability and that may be reduced based on how much is due to the job injury
    Last edited by .SH; 12-07-2009 at 05:23 PM.

  3. #3
    Join Date
    Dec 2009
    Posts
    6

    Default Re: W/C Settlement

    Is there a percentage of cause needed to obtain benefits?

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,943

    Default Re: W/C Settlement

    Quote Quoting OW!OW!OW! View Post
    Is there a percentage of cause needed to obtain benefits?
    No... WC is no fault... where there is a accepted claim of injury, benefits are provided... wage loss while you treat/recover, and the provision of that treatment.

    PD indemnity is not a 'benefit' but an award. Your ER is liable ONLY for the % of PD/impairment due to THIS injury.
    Where there is pre exsisting causation to PD/impairment, your Dr must develope that record through medical reasoning to the amount or % to reduce the current rating %...that's called ''apportionment to cause''...of PD.
    You cannot apportion treatment...but you can PD...by determining what casued the PD.

  5. #5
    Join Date
    Dec 2009
    Posts
    6

    Default Re: W/C Settlement

    OK, I got a CDA, the Atty.s office faxed the info to SSD I have called SSD and yes they have the info but still I have heard nothing from SSD. Is it normal for the process to be so slow?

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,943

    Default Re: W/C Settlement

    You have applied, or are receiving SSDI ?
    As such you are Medicare eligible within 30 months of any settlement that changes/closes the medical coverage in your comp claim....

    Don't know what "CDA" is...
    Are you required to have a WCMSA/WC Medicare Setaside Arrangement included in the settlement proposal?
    The back logs at CMS or COB/coordinator of benefits that do the review/approval of a WCMSA is dependant upon the RO/Regional Office... so would a delay be normal...yeah, depending on the RO back log. NOt all WCMSA are actually reviewed and a letter sent to the applicant... that all depends on the RO work load.

  7. #7
    Join Date
    Dec 2009
    Posts
    6

    Default Re: W/C Settlement

    CDA= claims disposition agreement/lost wages. As for the WCMSA I am not sure. Anyway I have almost exhausted the CDA money to ensure my wife and I have a place to live for the rest of our lives while walking away from a mortgage I could no longer afford. I went to have my scripts refilled a while back and had to pay out of pocket because SAIF now says they will not pay. Even though medical is something that you cannot lose in oregon SAIF tells my Atty they want to buy me out on my medical. Getting back to my original question, It has been 3 months that SSD has had the info about my w/c claim CDA my SSD claim was accepted but w/c had the ball until now. I was counting on the monthly SSD income for monthly expenses

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,943

    Default Re: W/C Settlement

    If you have been receiving or awarded SSDI, and they are waiting for information on your WC benefits to calculate the right monthly benefits... you'll just have to wait until that issue is resolved. Depending on the backlog....SSA can take anywhere from 30 or 60 days to months before you see the money. Any retro benefits would be paid too, or taken as credit due to overpayment.

  9. #9
    Join Date
    Dec 2009
    Posts
    6

    Default Re: W/C Settlement

    I have another ? I stated before that my prescriptions were no longer paid for buy SAIF and I had to pay out of pocket. My ? is, Are`nt the prescriptions that SAIF had been paying for since Nov. 2008 part of the medical? and if they are then SAIF should be compensating me for the prescriptions that I have paid for out of pocket correct?

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,943

    Default Re: W/C Settlement

    Are`nt the prescriptions that SAIF had been paying for since Nov. 2008 part of the medical? and if they are then SAIF should be compensating me for the prescriptions that I have paid for out of pocket correct?
    For any treatment to be compensable in a comp claim, your Dr must provide the continuing medical necessity, meaning on an industrial basis, the service/medication etc is still "medically necessary".
    Just because they have paid for any extended period of time doesn't necessarily mean there is still a medical necessity due to the injury, and that functional restoration is the goal. With out that... a stated goal of restoring functional use of the body part you claim injury to... the medication may not be authorized.
    Even though you may have continued to treat/medicate, and pay out of pocket for the medications...there still must be shown the necessity on industrial basis.

    IW's can see any Dr they wish, treat to any extent they wish, doesn't mean the ER/IC is liable for those costs.
    That's a risk taken when you pay out of pocket.

    As you can see, it's not always an easy "yes/no" answer to the question as you pose it. "Maybe/maybe not" would better suit as the answer.

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