medicare

[congodog]

I am permanently disable due to an auto accident while at work. I am 61 yrs old and opted for SSDI. For health issues not related to my injury, I have health insurance via my wife's job. I signed up and have a medicare card but have never used it and likely never will for issues with my WC injury.
I am trying to get out from under the insurance company's control of my WC injury and I am attempting to settle with them. They we very positive at first after some incredible bureaucratic blunders, but now are low-balling me and dragging their feet. They also have begun a pattern of refusing treatments that are no-brainers.

Once the negotiation has started and they suddenly become dismissive and truculent. I want to take then to court for refusing to negotiate fairly and in good faith. I need them out of my treatment path in order to obtain the help I need.

Can I sue them?

[Still in Limbo]

You can't "Sue" Workers Compensation, but You can take them before a Hearings Judge, and have the Judge Decide what Treatment is Reasonable and Necessary to Your Injury, and in Some States, (You didn't Post Yours), they can Access a Penalty for Lack of Medical Care, and also for Lack of Prescription Meds. on a Normal Basis. If You have a Letter from w/c Denying You Treatment, Medicare will Pay for it, and they will Attach a Medical Lien to Your Case, and if You Win, the Ins. Co. will have to Reimburse Medicare, and You for the Co-Pays. I didn't Notice if You Mentioned if You have an Attorney Helping You on Your w/c Case, but if You don't, I would Suggest You think about getting One, there are a Lot of Loop Holes and Pit Falls in the w/c Systems, and they know how to Navigate them! I Hope this Has Helped, Welcome to the Boards, and Have a Great Day!!

[1171]

if you do manage to settle with them you have to put part of the proceeds in a medicare trust account that'll be used to pay for the work comp treatment.
workers comp has it's own court system to handle disputes. You have to start there for any legal matters.
if you want more details you'll have to provide your state as the rules are specific to each state jurisdiction.

[congodog]

1171 Wrote:if you do manage to settle with them you have to put part of the proceeds in a medicare trust account that'll be used to pay for the work comp treatment.
workers comp has it's own court system to handle disputes. You have to start there for any legal matters.
if you want more details you'll have to provide your state as the rules are specific to each state jurisdiction.

If I settle, in California, I thereby release the wc insurance co from any more medical payments which makes this response not make sense to me. Am I reading it incorrectly. All responsibility for medical treatment relative to the wc injury is mine. That's the point of the "settlement", no?

[1171]

yes that's correct. your responsibility and also not medicare's.
And to make sure you continue to have money to do that medicare requires that you put part of the settlement into a trust account.
you can learn more about it from their website
http://www.cms.hhs.gov/WorkersCompAgencyServices/
or here
http://www.medicareapproval.com/t0.htm
however once it's in the trust account it's not subject to the same medical restrictions as if the comp carrier was still providing but it does make settlements more time consuming.

[Lilly]

It's called a 'set aside' .

Lilly

[Still in Limbo]

I'm in Pa., and this Should Work for You also in Ca., when in Settlement Negotiations, We Split the Settlement Process into 2 Categories, First the Indemnity Portion which is the Amount of Money I would Receive Personally for My Case Lump Sum, and Second the Medical Portion. So in Other Words x Numbers of Dollars for Me, and they are to Fund the Set-Aside Separate from that Amount. That way We can Settle and get my Money Quicker, and if they can't come to Agreement with Medicare, then the Ins, Co, must Bear the burden of My Medical Care for My Injury for Life. I don't know if You can Split Your Case or Negotiate a Settlement in Ca. but I Hope You can, and It Works for You! Best of Luck!!