[californiaworker]

Hello All:
I've been browsing these threads for awhile as I muddle through 2 California work injuries, one represented, the other not. While I have found alot of useful and intriguing information, I have been equally confused by much conflicting and contradictory advice. I would welcome any knowledgeable input. Here's my story:

The insurance company (IC) has accepted the doctor's QME report and my associated PD rating. Thus far, the IC has paid just shy of $10k for my medical treatment. My future medical could range anywhere from $500 per year to $300k+ if my condition deteriorates and I need surgery 10 years from now.

Not surprisingly, I received a settlement offer from the IC indicating that they would like to pay an additional sum of $$$ in order to buy out future medical. I currently have private insurance (PI) that covers 100%. My initial thought was NO WAY, even if you throw $100k at me now, I can't be on the hook for $500k somewhere down the road. But I realize that there is more to this and don't want to make a rash decision.

THE QUESTION: My PI has never had an issue with covering pre-existing medical problems. It's my understanding that the Affordable Care Act (ACA) has further locked PI companies into paying for pre-existing conditions. I'm in my 30's and nowhere near retirement age or qualifying for Medicare, so I don't think that a Medicare set-aside comes into play here. I will likely always have great PI through either my employer or my spouses employer. So, I am wondering if there is any measurable risk to having to pay for future medical by accepting a large settlement. Does this risk hinge on the ACA being repealed or changed? My gut feeling is that this is TOO risky, and I will likely need some future procedure that the IC should pay for. On the other hand, it sounds like once you reject a buy-out and opt for a STIPULATIONS only settlement, that the IC just starts denying treatment and making your life generally miserable, so you probably don't get the best treatment anyways. If this is to be expected, maybe I should just try to get a large settlement and cross my fingers that the ACA protects me by making PI pay?

Any thoughts on this?

[California_Help]

(03-06-2014, 02:08 PM)californiaworker Wrote: Hello All:
I've been browsing these threads for awhile as I muddle through 2 California work injuries, one represented, the other not. While I have found alot of useful and intriguing information, I have been equally confused by much conflicting and contradictory advice. I would welcome any knowledgeable input. Here's my story:

The insurance company (IC) has accepted the doctor's QME report and my associated PD rating. Thus far, the IC has paid just shy of $10k for my medical treatment. My future medical could range anywhere from $500 per year to $300k+ if my condition deteriorates and I need surgery 10 years from now.

Not surprisingly, I received a settlement offer from the IC indicating that they would like to pay an additional sum of $$$ in order to buy out future medical. I currently have private insurance (PI) that covers 100%. My initial thought was NO WAY, even if you throw $100k at me now, I can't be on the hook for $500k somewhere down the road. But I realize that there is more to this and don't want to make a rash decision.

THE QUESTION: My PI has never had an issue with covering pre-existing medical problems. It's my understanding that the Affordable Care Act (ACA) has further locked PI companies into paying for pre-existing conditions. I'm in my 30's and nowhere near retirement age or qualifying for Medicare, so I don't think that a Medicare set-aside comes into play here. I will likely always have great PI through either my employer or my spouses employer. So, I am wondering if there is any measurable risk to having to pay for future medical by accepting a large settlement. Does this risk hinge on the ACA being repealed or changed? My gut feeling is that this is TOO risky, and I will likely need some future procedure that the IC should pay for. On the other hand, it sounds like once you reject a buy-out and opt for a STIPULATIONS only settlement, that the IC just starts denying treatment and making your life generally miserable, so you probably don't get the best treatment anyways. If this is to be expected, maybe I should just try to get a large settlement and cross my fingers that the ACA protects me by making PI pay?

Any thoughts on this?

You may be getting contradictory advice as those who post on forums are not attorney's and you should really consult with one to get the best advice.

It was my understanding it is not yet known if the ACA covers work related injuries, that are accepted and signed off with a C&R.

Can you please provide information that stated Affordable Care Act covers work related injuries after a person has signed a compromise and release?

Do you have a copy of your private insurance policy that states in writing you are covered with a work related injury after signing off on a C&R ?

This topic is being discussed on forums where attorney's and others in the industry post and they are stating they do not know if work related injuries are covered. If you have information that states this, it would be helpful to others. I will send you a thread about this topic in a pm.

I recommend talking to your attorney about this. I also recommend getting a copy of your private insurance policy to make sure it is covered before making any decisions.

[1171]

the law on ACA and workers comp is not established and there are only opinions now.

I don't think ACA will provide duplicate coverage for pre-existing conditions.
it is not clear at this point if ACA will consider your acceptance of a settlement amount as "no coverage".
I also don't think ACA can make your PI offer coverage for something you received a settlement for.
you are correct to be suspicious about counting on a potential windfall for all the comp claims that settle.

the medicare secondary payor provisions may be seen as an example of how ACA will treat comp settlements.
I also don't think your carrier will change it's behavior on treatment just because you've settled. I suspect their UR procedures are fairly uniform regardless of the type of claim.
it would very inefficient to have separate UR units and rules not to mention illegal and subject to fines by the audit unit for targeting future medical award cases.

if you have a complex claims situation, you should consult an experienced work comp atty.
if both claims are with the same carrier for similar body parts and you are still with the same employer, I'd be surprised if they would settle only one.