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  1. #1
    Join Date
    May 2017
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    Default Relocatiing to Tennessee

    Hello All,

    Looking to gain some knowledge, so I appreciate any input or suggestions received. I have been suffering from a back injury and another orthopedic injury for almost five years now. I have been told that I am in need for back surgery however I need to lose weight prior to back surgery treatment(which I have been working on). I am relocating from California which is the place in which my injury occurred to Tennessee this summer. When i let my attorney know that he said to me it will be "nearly impossible to find a workers comp attorney in TN because they do not like treating patients from CA. He is suggesting I take a very low settlement offer and run. However I have NO interest in accepting an award especially of this dollar amount. My sole interest is in receiving the proper medical care so that I may make a recovery. On a scale from 1-10 my pain is generally a 10 most days, so a micro award is not of any interest to me.

    So, my question is, does anyone have any experience or knowledge switching doctors from CA to TN? Any suggestions? Any suggestions?

    Also, the workers comp company is absolutely horrible, which I am sure many of them are, I receive denial after denial for medical treatment. However, I am interested in hopefully receiving the proper back treatment surgery once I am down to my targeted weight zone from the insurance. In the event I am forced into settlement. What are the odds of being able to pursue back care/surgery through a private insurance? Likely slim to none?

  2. #2
    Join Date
    Oct 1971
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    5,044

    Default Re: Relocatiing to Tennessee

    I deleted your other post in the California board, you can't double post the same posting - it confuses the board.
    You better listen to your attorney, you're creating nothing but problems for yourself.
    If you are lucky enough to find another doc in Tennessee, there's no guarantee he'll agree with your California doc - he may say you don't need surgery.

    If you settle, your private insurance will not cover a work related injury - you'll have to use the money from the settlement allotted for medical to pay for future treatment.
    It's never a good idea to move out of state in the middle of an open comp case, it never works out well.

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  3. #3
    Join Date
    May 2017
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    3

    Default Re: Relocatiing to Tennessee

    Quote Quoting tony View Post
    I deleted your other post in the California board, you can't double post the same posting - it confuses the board.
    You better listen to your attorney, you're creating nothing but problems for yourself.
    If you are lucky enough to find another doc in Tennessee, there's no guarantee he'll agree with your California doc - he may say you don't need surgery.

    If you settle, your private insurance will not cover a work related injury - you'll have to use the money from the settlement allotted for medical to pay for future treatment.
    It's never a good idea to move out of state in the middle of an open comp case, it never works out well.

    Tony
    Thank You,

    This has been my self realization today. However, in the even that I need to pay for future medical care and I use the settlement amount for treatment for this injury, will private insurance make up the difference? Or will I solely be responsible for whatever costs arise? My apologies regarding the double post.
    Last edited by Sad; 05-24-2017 at 03:44 PM.

  4. #4
    Join Date
    Oct 1971
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    5,044

    Default Re: Relocatiing to Tennessee

    Quote Quoting Sad View Post
    Thank You,

    This has been my self realization today. However, in the even that I need to pay for future medical care and I use the settlement amount for treatment for this injury, will private insurance make up the difference? Or will I solely be responsible for whatever costs arise? My apologies regarding the double post.
    Read the subrogation clause in your private health insurance policy - They won't pay for a work related injury - period.
    You need to consult your lawyer - he can give a definite answer based on the facts of your case.

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  5. #5
    Join Date
    May 2017
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    Default Re: Relocatiing to Tennessee

    Thank You, Tony.

  6. #6
    Join Date
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    831 East Morehead St., Ste 355, Charlotte, NC 28202
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    Default Re: Relocatiing to Tennessee

    Generally speaking, health insurance policies will in fact pay for that treatment, after a full and final settlement of your comp case. Without getting too arcane, this is because the "work related injury" exclusion in the health insurance policy applies to injuries in which there is another insurance company on the hook to pay for that treatment. After a full and final (C&R) settlement, that workers' comp insurance company is no longer obligated to pay for those medicals, so they are no longer "on the hook" and the health insurance then has no contractual exclusion that applies, so health insurance is obligated to pay. If this were not true, health insurance would never pay for medicals in a denied work comp injury setting, and health insurance pays those meds all the time. Subrogation would only apply to past payments, before the settlement. This is general information and you should only rely on legal advice from your own attorney. Nor does this analysis apply to Medicare, due to the Medicare Secondary Payor Act.

    But you will find it close to impossible to get a doctor in TN to accept workers comp from California. Remember, no doctor is obligated to treat you unless your life is in danger. So doctors can refuse to see you for a comp injury for the rest of your life.

    Talk to your own attorney about these questions.
    The North Carolina Court of Appeals has held that "In contested Workers' Compensation cases today, access to competent legal counsel is a virtual necessity." Church v. Baxter Travenol Labs, Inc., and American Motorists Insurance Company, 104 N.C. App. 411, 416 (1991).

    Bob Bollinger, Attorney and Board Certified Specialist in NC Workers' Compensation Law

  7. #7
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    Default Re: Relocatiing to Tennessee

    complwyr
    After a full and final (C&R) settlement, that workers' comp insurance company is no longer obligated to pay for those medicals, so they are no longer "on the hook"
    The reason the comp carrier is "off the hook" and no longer obligated to pay is because they've paid the bills by paying future medical - they've fulfilled their obligation.
    You can't then file a second claim and submit paid medical bills to your private insurance to enrich yourself - that's the legal definition of "double dipping" it's a form of fraud.

    Insurance double dipping occurs when a claim is filed with two different insurance companies. This can happen with auto insurance or health insurance, and is against the law in the United States.
    For legal purposes, filing the same or similar claims more than once, whether different insurance companies or the same one, is a type of fraud and may be treated as a felony offense.
    For health insurance, double dipping is when a single medical procedure is claimed twice, either through multiple insurance plans or through the same plan filed at separate times.
    https://usinsuranceagents.com/answer...with-insurance

    Definition of Insurance Fraud
    Insurance fraud refers to any duplicitous act performed with the intent to obtain an improper payment from an insurer.
    Anyone who seeks to benefit from insurance through making inflated or false claims of loss or injury can be prosecuted.
    http://criminal.findlaw.com/criminal...nce-fraud.html

    What if you were injured on the job?
    Your health contract also contains a provision that excludes the payment of medical bills for work-related injuries
    and illnesses. This means that we will not provide benefits if workers’ compensation laws cover, provide or pay for
    the service, supply or treatment of any work-related accident or illness. In addition, if you receive a settlement for
    your workers’ compensation claim, we consider the settlement payment to be covered by workers’ compensation and
    we will not provide medical benefits for the injury or illness.

    https://www.southcarolinablues.com/w...ti_English.pdf

    Generally speaking, health insurance policies will in fact pay for that treatment, after a full and final settlement of your comp case.
    What you're describing would be a violation of the "basic principles of insurance"
    In cases "where the same subject matter is insured more than once" he may collect from one insurer for losses not covered by the other - he can't collect twice.

    I imagine the OP could pull it off if he failed to disclose and misrepresent the facts to his health insurance carrier, if or when they find out, he may be up on fraud charges.
    I'd love to see the OP call his private health carrier, inform them that he received a settlement from comp for future medical and wishes to keep the money and bill them and see what they say - that'd be funnier than hell.

    Private health insurance will pay any loss not paid in the comp settlement or if the comp case was denied, they will not pay bills already paid in a settlement to enrich the insured.
    I can't imagine a scheme where it would be legal or moral in any state for an injured worker to collect hundreds of thousands of dollars in future medical in a settlement, pocket the money and then bill his private insurance - it's the legal definition of fraud.

    Also, you are legally obligated to inform your private health insurance carrier of your intention to settle your comp case and afford them their right to subrogation or reimbursement, it's right there in black and white in your health care policy's TOS and subrogation clause - go through and read the contract you signed.
    Here's just a few sources to support my argument, there are hundreds more.

    Double Insurance Law and Legal Definition
    Double insurance is a type of insurance where the same subject matter is insured more than once. In such cases the same subject is insured, but with different insurers. The method of double insurance is considered a legal act. In case of loss the insured can claim from both the insurers and the insurers are liable to pay under their respective policies.
    The features of double insurance are:
    1. subject matter is insured with two or more insurance companies;
    2. the insured can claim the amount from the policies; and
    3. the insurer cannot claim more than the actual loss.
    Double insurance also follows the basic principles of insurance. Thus a double insurance does not allow for unjust enrichment of the insured.
    https://definitions.uslegal.com/d/double-insurance/

    Other Sources:
    REIMBURSEMENT CLAIMS BY ERISA HEALTH PLANS
    The bottom line in North Carolina: If medical bills are paid by a health plan obtained through a private employer, and if the health plan is “self-funded,” the plan provisions regarding reimbursement will generally be honored by a federal court.
    If a workers compensation claim is initially denied, so that an employee’s ERISA health plan pays the medical bills from a workplace
    accident, and if the workers compensation claim is later honored or enforced, the employee will have to reimburse the health plan, if the plan provisions so require.
    http://files.lm2014.gethifi.com/ERISA_Claims.pdf

    Federal case law is well settled on the principle that an ERISA health plan is entitled to reimbursement of benefits paid from personal injury settlement proceeds that are clearly
    identified as such.

    A recent decision by a U.S. District Court in Georgia in favor of the insurance plans right to reimbursement through subrogation indicates how modern federal
    courts dispose of those arguments.
    The case is Brown and Williamson Tobacco Corporation v. Collier, 2010 WL 1487772 (M.D. Ga, April 13,2010 )
    In that case the district court rejected the Georgia “Make Whole” Doctrine.

    An ERISA insurance carrier can sue the client for subrogation. An ERISA carrier can also cancel your health insurance or refuse to pay claims you submit for medical care for
    failing to agree to pay subrogation or to sign a subrogation form letter.
    http://www.emarcusdavis.com/lawresou...al-injury-case

    Tony
    Last edited by tony; 05-29-2017 at 12:17 PM.
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

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