Good Morning to you and THANK YOU so so much for all the info!
Sounds like you and my husband have much of the same everything...We are dealing with CIGA, bc our WC company went BK....Atlantic Mutual, we also deal with Intercare. We have gotten ANOTHER adjuster, who refuses to speak to me bc she said that we had an atty some years ago, he is now a Judge in the WC Division in N Cali. I have been handling this since 2006. My husband was deemed 100% P&S in 2004. He had another surgery 2 years ago, and truly needs another on his neck, but he is not wanting it.
The new adjuster has REFUSED to ok a Pain Mgmt Dr here, saying that she has never received a request...its been 6 months, now she is not allowing my husband to see his surgeon anymore....he will be out of meds in 10 days. I have been doing everything I am able to do to try and get her asst to get the OK for the Pain Dr....
The other adjuster who wanted to get us a MSA and settle no longer works there and we have this new lady, and boy howdy, she is a trip. We have not been treated this badly since the beginning of his case back in 1999. I am at a loss. Our atty is now a judge like I mentioned and it has never been an issue with anyone from CIGA or Intercare speaking to me before. We have no one to speak for us and we do not know of any atty who would touch this case since it is basically OVER.
My husband used to have a nurse come in 7 days a week, but the IC stopped that years ago. I have been his sole caregiver for years. I love him and am sick bc she wont ok the Pain Dr. I am at a loss....
Since they had previously discussed settlement and MSA....I wonder if I can get someone there to try and move forward with it. They do not have direct deposit and we are at the mercy of the mail...we do not get reimbursed for mileage or any meds we have paid out of pocket for, except the one time a year or so ago...
My husband has been on SSDI since 2000. Sad and good at the same time, he was 45 when he applied, and received it on the 1st attempt. His Medicare kicked in 2002, but we use that for regular dr visits.
Thank you again for the information. I am going to be on the phone again 1st thing in the morning to try and see if I can get her asst to try and get the ok for the Dr, who is in their provider list. The case of from California but we live in Nevada.
I am hoping to make some headway this week. Thank you again!!!!!!!!!!!!
(12-07-2014, 05:24 AM)SharifahRosso Wrote: (05-19-2013, 11:59 PM)1171 Wrote: CIGA is not an Insurance carrier and there are no penalties for them.
CIGA is a special fund that acts as a safety net to catch the liability for workers that otherwise would just be dropped without any coverage.
I'm not sure the usual complaint process would apply to the fund but you won't know until you try.
CIGA created under California law to provide a limited fund for the payment of some, but not all, workers' compensation claims...
CIGA is authorized to pay and discharge only certain "covered claims" as that term is defined under California Insurance Code Sections §1063.1 and §1063.2. The "covered claims" that CIGA is authorized to pay may be more limited and/or restricted than the coverage that would have been afforded under the policy issued by the insolvent and liquidated insurer.
http://www.caiga.org/
I assume you've tried writing, calling, and emailing them..
http://www.caiga.org/contactciga.html
You might also consider using their ethics hot line
http://www.caiga.org/ethicscompliance.html
Although CIGA is not an Insurance Company per se, it does hire Third Party Administrators (Insurance Companies' Claims Management Services) to administer the claims. Since 1984 my Work Comp claim, under CIGA, has been managed by GAB Business Services, Helmsman MGMT (a sub-division of the International LIBERTY MUTUAL Insurance Company), Intercare, and now Sedgwick CMS.
The claims are supposed to be handled equitably and fairly, as if by the original insurance company (which was Mission Insurance, which went bankrupt, which is why CIGA is involved in the first place). CIGA Contracts various Third Party Administrators, who hire WC Defense Attorney Legal Firms, and through one's own Attorney one may negotiate a compromise and release "settlement". It is very time-consuming to negotiate a final compromise and release settlement (that can take several years), and even though the final numbers might be reached between the Injured Workers and CIGA's contracted Third Party Administrator's Attorney, one has to additionally consider the Medicare Set Aside process - which can take another 3-12 months, or longer.
However, MEDICARE IS SET UP TO PAY YOUR BILLS "CONDITIONALLY" should Work Comp provide you a formal denial for particular care. Since your spouse is on SSDI, he should also be getting Medicare. My understanding is that if Work Comp denies medical care, then one may request Medicare to provide it. (I assume this is true of prescription drugs also.) When Medicare pays "Conditionally", then at the time the claim is settled Medicare is entitled to "RECOVER" any funds it has paid out to cover your Work Injury costs, and it has a right to request that the Work Comp Insurance Carrier (CIGA's Third Party Administrator) provide a Medicare Set Aside fund (which can be a structured settlement with an initial "seed money" outlay, followed by yearly deposits (depending upon an actuarial study of how long the injured worker will live). At any rate the amount of the Medicare Set Aside needs to be approved by CMS, so that you are not jeopardized later on, and denied care by Medicare entirely. However, Once the MSA account (which must be a separate reporting account) is established, and used up for paying work comp medical expenses, then Medicare will "kick in" and pay whatever medical expenses they would have otherwise paid had the medical condition not been attributed to a Work Comp Injury.
CIGA probably will contract MSA company(ies) to evaluate your claims (such as Crowe-Paradis and/or MEDVAL) that will "low ball" the MSA figures. This is to everybody's detriment in my opinion because Medicare will come back and ask for more money to be set aside if Medicare's analysts provide a higher figure than what the MSA Contractor came up with for the MSA portion of the settlement offer.
Other things to consider in a compromise and release is Home Health Care. Medicare does NOT provide for non-medical home health, and if you need it, it will have to be considered in your award (which can be structured settlement that is usually to the insurance company's advantage, or a lump sum award). It is very complicated and time-consuming to work out settlement's and all the different types of funds that might be needed to complete a settlement, so you should make arrangements to get your medical needs taken care by at least Medicare in spite of Work Comp's denials.
In my opinion, one cannot maneuver this system without an outstanding attorney. I recommend that you become acquainted with http://www.avvo.com/?&utm_medium=sem&utm...fgodTl8AOQ
They are an excellent resource for free reliable legal advice, and rate attorneys - according to your area of need, in this case Work Comp, and by your location. Get a 10 rated attorney who knows how to get you through this, but don't expect immediate results. It can take several years to reach a settlement agreement between attorneys, but then add on to that another year to determine the Medicare Set Aside (although new Federal legislation was introduced on July 31, 2014 to help with this process one never knows how long it will take - or in what form - the new regulations will take to pass Congress, and if the President will sign it into law).
Medicare, in fact, recently has combined its previous Coordinator of Benefits Department and its former MSRPC, which is now renamed COORDINATOR OF BENEFITS RECOVERY CENTER. They also have information about the MSA on their website: http://www.cms.gov/Medicare/Coordination...rview.html
God bless you and all the other injured workers who are subjected to this very difficult system.
PS: I have primary discussed the Medicare Set Aside aspect of the C&R Settlement. There are other factors to consider such as Permanent Disability ratings, Home Health (not provided by Medicare), Transportation needs for the Disabled, Computer Needs, Liens (which should not affect you directly), etc. You must have legal representation to protect yourself and your future, and to have enough funds put aside for your needs.
She has been doing her best to get things going.....this morning when I spoke to her, she asked if we were willing to do a medical buyout....she said she would get a package together by the 1st. Maybe things are going to get better after all!
