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Settling Future Medical for PTSD
I am a 25 year fire captain from California. My original date of injury is 2006, but I was able to work until 2013, when I was forced to retire due to this second instance of PTSD. The claim was accepted immediately but I was not entitled to 4850 time since it was not a new injury but an exacerbation of the 2006 injury.  I was awarded a disability retirement and the wc carrier has never denied any treatment. I moved out of state to avoid triggers. WC has provided psychological care, psychiatric care, medications, massage, yoga, gym membership, etc with no denials or delays. I have never been in an adversarial position with them or my employer. Recently the QME (I am unrepresented, btw) declared me P & S and the report was sent to the adjuster, who rated me at 36% PD and has been paying me bi-weekly with back pay to the date I was P&S. The report has been forwarded to the state for rating.

I estimate my medical care and associated costs to have been $30k per year over the last 2 years. The QME stated my condition has plateaued but could get worse or better and recommended future medical care, including the massage, yoga, medications, psych care, etc. 

I have 2 questions. I want to negotiate settling my future medical care into a lump sum payment. I am 54 years old. Assuming I could live another 30 years or more, and my care could cost $30k per year, more or less, what would be a fair settlement amount? I realize it will NOT be 30 years x $30k, but what WOULD be reasonable? It is well known that long term stress causes other medical problems, so I don't want to run out of $ in 10 years.

It is difficult to find care providers in TX who accept CA work comp payments, so I will be paying out of pocket, likely at a rate higher than wc currently pays. For instance, one of my meds costs $1500 a month, but wc only pays $500. My point is that I may be paying more than $30k per year, but I will not have to pay out of pocket and then wait forever for reimbursement.

I would appreciate if anyone knows how they estimate how long you will live and how much they pay, knowing how much your has cost to date.

Thank you.
generally negotiations take place within a range of possibilities; a low end being medical usage with maintenance treatment tapering off over time and a high end with possible complications and increased treatment as one ages.
a settlement amount falling somewhere in between depending on the medical evidence and arguments each side can make.
You can find the social security life expectancy table here
you really should not guess at your medical usage. you can request a print out of treatment paid to date from the carrier that will help provide an more realistic usage figure. concentrate on the maintenance level rather then the acute post injury recovery phase.
you also must compute a present value amount. even though interest rates are currently low the cost of the future benefit money paid upfront is not negligible. generally it cuts the amount anywhere between a third and half.
you can use a spreadsheet function or something online

there is another factor to consider. Medicare secondary payer laws allow a carrier and a worker to setup a setaside agreement with CMS approval that will stipulate how much of the settlement is to be used for medical treatment. This will allow Medicare and the worker avoid the friction over trying to get medicare to pay for treatment that the worker received settlement monies for.
more on set asides here

there maybe other considerations but that should get you started.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
Wow. That is a great deal of good information - thank you so much. I read your response several times and followed the links. My guess of living another 30 years was pretty close to ssa.gov's calculation. The value of money link was valuable, but returns more $ than I anticipated, so I might have made a miscalculation somewhere. You are wise in suggesting I not guess at how much my care costs and will cost, but my acute post injury phase was far less expensive than the maintenance phase. When I first went off duty, I had weekly psychological visits, but the only medication I had was daily omeprazole (the stress caused terrible stomach acid production), occasional Xanax for anxiety attacks, and a small dose of flexeril (a muscle relaxant) because I tensed up my muscles at night during near-all-night-long nightmare/night terror sessions. After moving to Texas, the new psychologist wore me down and I sought out an experienced PTSD psychiatrist who prescribed anti-anxiety meds twice daily, an anti-depression patch worn 24/7, the omeprazole, a sleep aid and a huge dose of flexeril, as the nighttime muscle tension has not abated. I also take Prazosin daily to deal with the nightmares. I still have them, but I don't remember them, and therefore I still tense up my back, neck, shoulder, and jaw muscles every night and wake up a frozen, terrorized mess. To help alleviate this, the QME doc recommended yoga, sitting in a hot tub, stretching, meditation, and massage therapy. It has been approved each time my primary treating physician (the psychiatrist) has requested it. This is why I think my maintenance costs are more $ than the initial costs. I would love to try more of the eastern medicine treatments that wc would not likely consider and decrease the amount of medications, which is why I want control over my medical costs.

As for the Medicare piece, I'm not that familiar with how it works but I paid into my department's retiree medical plan since day 1 and I have excellent health care for life. Also my disability retirement is largely (about 75% tax free) and I have no debt. My husband is an executive 9 years my junior, so I doubt I will ever run out of money needed to pay for treatment if things go sideways somewhere along the way.

I just think it's easier to budget a physiological injury than a psychological injury. PTSD was caused by 25 years of trauma in a busy major metropolitan department serving a densely populated area punctuated by a few major national incidents of a horrific nature.

There are many studies out there, but the majority are veteran related, and I do not believe first responder PTSD to be the same on many different levels. Even with treatment and medication, unexpected situations will trigger horrible flashbacks, anxiety, panic, and night terrors. My plan is to gather as much data as possible to make my case, if I need to. So far, I have been treated more than fairly and I do not anticipate a sudden turnaround. If the initial offer is reasonable in my estimation, there will be no need for negotiation. I am not a gold digger - I just want fair treatment. In order to know what is fair, though, I need to have some idea of how to calculate my future cost of care to a reasonable extent.

Again, thank you for such great advice so quickly, I really appreciate it.
you are more optimistic than many that venture into workers comp settlement territory alone.
there is no reason to assume that the carrier will be willing to settle yet so you could strike out with your initial demand.
the carrier is not required to give you a buy out.
you and the carrier can settle at any time, so if neither can come to an agreement now it could happen any time during the claim.
you ,of course, can check with your health care plan to see if they will provide treatment should you settle.
if you are dealing with a large settlement amount, there is a third alternative.
structured settlement or annuity purchase. interest rates are historically low so the greatest advantage of an annuity is lost but a carrier purchase of an annuity does avoid the proceeds from being taxed. an annuity also allows you to structure the payout any way you wish with periodic payments as well as periodic lump sums. you also can guarantee the payment duration and provide for beneficiaries (neither of which comp does).

with many options available you are in a good position to get something you can live with.

P.S. as a public safety officer I suspect your union is affiliated with a work comp law firm so at any point you do have access to an experienced lawyer. they may even "advise" you without filing for official representation and fee.

P.S.S. there should be some resources/studies from New York. Their workers comp board setup a special program to handle post- world trade center attack claims and physicians there may have developed and published some effective treatment regimes. there were approximately 2400 PTSD/psychological stress related comp claims filed in New York.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
Ha - too funny. Why wouldn't I be optimistic when I have never been in an adversarial position with my employer or the wc carrier? The adjustor has already indicated they will be ready to settle my case as soon as they get the rating back from the state. Maybe we have differing opinions on what "settle" actually means, but it is my impression that she will begin the negotiations by making an offer.... And I can accept the offer or counter it. I anticipate the offer to be fair without having to negotiate or getting an attorney. I guess that does sound optimistic...... I know my health plan won't cover anything work comp related.... I have already received questionnaires from a 3rd party subrogation firm asking if my last regular doctor visit (to get birth control pills renewed) was work related. Wth!? I seem to get one after every regular doctor visit now, but I have no need to use my personal health insurance as all of my needs are met on the wc side. I think the problem is that the doctor put work related PTSD in my history and now they question every visit, regardless of what it is for.

Again, thank you for the great advice - I'll move forward with more wariness and more facts on hand when the time comes. I'm sure everything will work out. :-)

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