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set a side - Hoosier_Daddy - 02-10-2010

Hi, been awhile since i have been on here. I have a question for all of you. I won my SSDI case in June of this pat year and my WC claim in November. Well my attorney for WC must of thought I was already on medicare because part of the settlement was a set a side for 12,6000 for future surgeries. I am eligible for medicare in May. I go for a MRI on Friday and will no doubt have another knee surgery a short time after. What I was wondering is do I use my wife's insurance for the MRI and surgery and use the set a side for the difference or use the set a side for whatever it will cover. We have used my wifes insurance in the past for other surgeries. When I won they received a big chunk of payment for the past surgeries as well. I have an email in to my attorney to try and get an answer. But I thought I would see if any of you knew the answer. Thanks all!


RE: set a side - 1171 - 02-10-2010

the set aside is to be used for medical treatment for settled work comp injuries. once the set aside is exhausted medicare will kick in from then on.
heath insurance should not be used for covered work comp treatment; however if they are willing and don't mind waiting and applying for reimbursement from the setaside fund there is no harm in using it.
the work comp carrier will no longer reimburse them since the claim is settled.


RE: set a side - Hoosier_Daddy - 02-10-2010

My question is, I will not be eligible for medicare I think until May. I won SSDI with a back date of December of 2007. There is a 2 year and 5 month wait time. If I have the surgery before May how will that work. There is only 12,600. That will not cover everything. My wife's insurance was paying for all of the past surgeries. They settled for exactally half of what they paid. So are they telling me they are done with my knee issues or would they continue to pay for future surgeries as long as we met the co pay issues. Sorry for rambling but I have no idea how any of this stuff works.


RE: set a side - 1171 - 02-10-2010

I would think your wife's health coverage would pay during the gap period but the only reimbursement rights they would have would be against the set aside funds.


RE: set a side - Hoosier_Daddy - 02-10-2010

1171 thanks for the information. Hopefully my attorney will get back to me on this. They only gave me 12,600 for future treatment. It may be in my best interest to wait until I am eligible for medicare.


RE: set a side - freebird - 02-10-2010

Hoosier_Daddy Wrote:1171 thanks for the information. Hopefully my attorney will get back to me on this. They only gave me 12,600 for future treatment. It may be in my best interest to wait until I am eligible for medicare.

IF this upcoming knee surgery is caused by your work related injury, Your MSA will have to be used. When it is exhausted, your insurance plan thru your wife will kick in provided her IC does not have a rider on your work related Injury.

If your wives IC will not pay, then you might have to wait for Medicare to "kick in" before you have the surgery.

I can tell you Medicare will not be happy that your MSA was not properly funded. This could result in fines for all parties. Your cost of future surgeries should have been in your MSA.

Personally, If I understand you correctly, You have a problem.

Why was your MSA so low? Did you and your Attorney look at the MSA proposal before it was sent to Medicare to see if it was properly funded? The IC will rip you and Medicare off and not blink a eye.

Once CMS approves the terms and amounts of the MSA within the settlement offer prior to adoption, the potential for re-examination is negated.


RE: set a side - freebird - 02-10-2010

Hoosier_Daddy Wrote:
What I was wondering is do I use my wife's insurance for the MRI and surgery and use the set a side for the difference or use the set a side for whatever it will cover. We have used my wifes insurance in the past for other surgeries.
When I won they received a big chunk of payment for the past surgeries as well.

This was a subrogation claim filed by your Wifes Insurance Company meaning they received pay from the IC for services rendered due to your work related Injury. [b]


I have an email in to my attorney to try and get an answer. But I thought I would see if any of you knew the answer. Thanks all!


RE: set a side - 1171 - 02-10-2010

"subrogation" is a very specific legal term used to describe 3rd party liability that overlaps workers comp.
when there is no third party liability the correct term is "lien" or reimbursement rights.


RE: set a side - freebird - 02-10-2010

1171 Wrote:"subrogation" is a very specific legal term used to describe 3rd party liability that overlaps workers comp.
when there is no third party liability the correct term is "lien" or reimbursement rights.

OK....

http://insurance.freeadvice.com/information/auto/article/50