Hello There, Guest! Login Register
Index    |     Search    |     Members    |     Help

Thread Rating:
  • 1 Vote(s) - 5 Average
  • 1
  • 2
  • 3
  • 4
  • 5
if i settle...
I have sent you so many credible sources. Please send me something that goes to the website for the employer base insurance who is stating they will not cover your work related injury after you close your WC claim. I will absolutely call them.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
(07-22-2018, 01:35 AM)California_Help Wrote:
(07-21-2018, 03:46 PM)Shadow Wrote:
(07-21-2018, 12:06 PM)California_Help Wrote:
(07-20-2018, 12:34 AM)Shadow Wrote:
(07-19-2018, 08:27 PM)California_Help Wrote: Could you post the Health Net Policy ?

Feel free to call Healthnet 800-522-0088

Again if Medicare is your primary insurance you do not qualify to purchase insurance on insurance exchange or if you are asking insurance companies about policies outside of the dates in the link above Nov 15 through Jan 1st.

You did not answer if Medicare is your primary insurance. If so this is your problem because you do not qualify for Obamacare. If Medicare is secondary to your spouses insurance you should be fine. Do you understand?

Here we go again . I'm not interested in going back and forth with you again .

No one, and I mean no one can provide a policy that does not exclude work related illnesses or injuries.

I have medicare and my wife's insurance will not act as a secondary and her policy clearly excludes work injuries, Blue Shield

Personally I think you try to convince others to make your self feel better about what you believe.

No I don't understand ....sorry.

Anyone that can provide a policy that accepts work injuries .I'll buy you a cake at any bakery in the unites states.

Free cake anyone Smile

When you close your wc claim you no longer are covered by the work comp system. This is what you are not understanding. I provided you with plenty of links and you have not provided anything to prove your assertion. I also provided you with a phone number to call and ask if they cover injuries from a CLOSED work comp claim and you will not even do that. You have no interest in finding help. How about you give me the phone number for your wife's private insurance and let me call them and see what they say? Anyone reading this can call the number I provided and see who is correct.

Shadow your behavior is trollish. You apparently have no interest in obtaining different private insurance because if you did you would have called the number I provided. You just want to argue and spread inaccurate info. I will be awaiting your private insurance phone number. Prove to me you are not trolling as I will absolutely call it and check if what you are saying is correct. Anyone can call the number I posted above.


Anthem Blue Cross @ 1-855-634-3381 under Evidence of Coverage page 155 ,under recovery and reimbursement. Work injuries are excluded.

HCID 947A54012
Contract Code 1FZ3lu
Category Code 1N

Anthem Blue Cross ,
Po Box 9041
Oxnard ,Ca 93031-9041

Closing the medical portion of a claim means you ( the claimant ) has accepted payment for the employers liability and now become contractually liable for the private insurers recovery right.

Closing a claims medical does not nullify a private insurers contract provisions. Which is essentially what you are saying.

My Lawyer says no ..So do many other honest attorneys.

This is a representative listing of major exclusions and limitations. A more detailed listing can be found in the Combined Evidence of Coverage and Disclosure Form/Certificate.

Here is the exclusion :

Any conditions for which benefits are recovered or can be recovered either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if you do not claim those benefits

Please see here :


Actually I am trying to protect Injured Workers from selling their medical benefit based on mis- information ,or even the advice of an unethical attorney.

Please cite credible sources .. other than that it's just talk. No need to call me trollish.

I think this backs up what I am saying very nicely.

Cheers !

The link you provided does not go to any website. Please send the site link to site as well. The last time you sent a link like this it went to an insurance broker that was not part of Obamacare or an employer sponsored plan. Purchasing health insurance outside of Obamacare, they can do whatever they want. They can even deny pre-existing conditions. Is the phone number you provided for this or is it for your spouses employer based coverage?

You sure do write a lot like the moderator on this other forum, who is spreading false information even though a well respected attorney disagreed with him. This attorney is not unethical and one of the most respected wc attorney's in his state.

I have no further interest in speaking with you .We have been over this again and again. It only escalates in a negative way.

Now you cast stones , make false assumptions and allegations.

No, I'm not Tony.

Cheers !!
California_Help ,

I have been following posts discussing this topic. I found your advice logical and very helpful. I have researched and have spoken to a few attorney's and I agree with you..

Thanks for confirming ,
(07-17-2018, 03:36 AM)amberteresa Wrote: if i settle my comp case will i ever be able to have my injuries attended to by medicaid or another employer...
my lawyer is making it seem like once i settle my injuries are my own responsibility... is this true? what if i fall again at a different job and re injure the same areas???
does anyone have any insight on this?
because the IC is really putting pressure on me to settle and it feels like if i dont i may miss out... i do have some permanant restrictions but i feel like i could do very light work... maybe some sort of factory job... someone talk to me here lol..

Sorry but i still have not got the best advice

Is your attorney suggesting you would be better off to keep your medical open, or is your attorney simply making sure you understand that the w.c. insurance will no longer be responsible for your care? Good to clarify that with them if it's not clear to you.

The laws in CA are currently so skewed in favor of the insurance companies that I would advise anyone to get out of the CA work comp system as long as the settlement offer is reasonable given your injuries. If it's not high enough, negotiate with them.

Of course each person's circumstance is different so there is no one correct answer for everyone. Answers can be more specific to you if you can provide a little more information. I'll give information you and others can think about.

You don't mention your state, but you mention medicaid (rather than MediCal), so I'm guessing you're not in CA. You don't mention medical coverage by a spouse's insurance, so I am guessing you are not married. My answers will be geared accordingly.

Also, you don't give the impression you are close to retirement age or on Medicare (due to disability) currently. If you are either of those, then I would highly advise you to require an MSA (Medicare Set Aside) before you settle your medical if the entire settlement amount will be over $25K. If you don't have an MSA, then when you become eligible for Medicare, they can require you to show proof that you spent your entire settlement (not just the medical portion of your settlement) on work injury related medical care before they would ever cover your work-injury related care. I know at least one person this has happened to. I believe her w.c. case settled before MSAs existed and I'm guessing she was in her early to mid-50's when her work comp case settled, but I'm not absolutely sure on either of those.

If you are currently eligible for or suspect you will be eligible for Medicaid or MediCal, they may have the same rules as Medicare as far as spending (and showing proof) that you spent your settlement money on work injury medical care before they would cover your work injury care. As I think about it, the amount you receive from a settlement could make you ineligible for Medicaid or Medi-Cal (unless your settlement is put into a Special Needs Trust) because you would have more money in your possession than those programs allow. I don't know the rules as to who is eligible to open a Special Needs Trust but you can find some information about that on the internet.

If you receive settlement money and spend it on other things, I'd think that could possibly (negatively) affect your eligibility for Medicaid. This could be the type of scenario Shadow mentioned about someone he knows who is being investigated.

Even with a Special Needs Trust, Medicaid might cover you for non-work injury care, but require you spend the Medical portion of your settlement from the Special Needs Trust before they would cover your work injury care. These are all rules I don't know about but are very important for you to find out about in case you are not able to find another job or not able to find one quickly.

I agree with the information California Help has provided as far as other non-Medicaid/non-Medicare insurance. I am also in CA. If you settle the medical you should be able to get coverage by other, individual insurance, and if it's an ACA policy they should not be allowed to exclude your work injury care if you do settle the medical. However, if you aren't working and have to buy individual coverage, it could be expensive. It would be good to check as to what insurance you could buy and the cost as part of your decision-making. I think there are state or federal websites where you can see what various policies cost. Maybe this was part of what your attorney was thinking, but didn't spell out.

It sounds like you are not working right now. I believe it is standard, that if you settle the medical you would not be able to continue or return to work with the same employer, but it doesn't sound like you are thinking of working with your same employer.

If you go to a new job I believe ACA prevents group insurance from excluding pre-existing conditions even if it was a work injury (as long as you DID settle the medical so the work comp carrier is no longer responsible).

I suggest you check with your state's Department of Insurance on individual coverage, group coverage, and Medicaid so that you feel confident in knowing the rules/laws. They might refer you to another source for info on Medicaid. You need to know how each potential type of insurance works if your work comp medical is still open vs. when you've settled your medical with work comp.

I hope this information gives you and others some ideas of the sorts of things they need to learn about and consider in settling their work comp case. Each state has different rules, so I'm speaking from what I know with respect to current CA laws. Federal laws come into play too.

Your specific injuries and type of future care you might need, as well as your financial status, marital status (re potential spousal insurance coverage), etc. are all factors that affect your decisions.

Best to you in your decision-making.
(07-19-2018, 03:27 AM)Shadow Wrote: Got my attention for sure .. who is the private insurance company?

I have been looking for a private insurance company that does not exclude workers comp injuries for about ten years.

No private insurance company will touch me with a ten foot pole.

So please provide details for the rest of us to learn and share



You have medical open in your work comp case. That is a different situation than a work comp case with medical closed.
(07-21-2018, 11:49 AM)California_Help Wrote:
(07-20-2018, 08:18 AM)tbear6410 Wrote: When I was injured on the job, comp paid those bills and my work insurance covered everything else not associated with the injury.
When I lost my job, I got on my husband's work insurance. They refused to cover anything pertaining to the job injury. When I finally got on Medicare, they also refused to cover anything pertaining to that injury.
Medicare told me the only way they will cover is if I settle Medical and use that money first.. then they will cover if they deem necessary.
Even when my husband changed insurance company's.. They too refused to pay anything...

They will not cover open work comp claims, but should cover denied treatment. Many patients use Medicare and private insurance for denied claims or denied treatment. There is a process to go through before you can use Medicare and need to show proof of denial. Since you are in a situation where Medicare is secondary, you need to use your husbands private insurance as primary or Medicare will deny everything. Have you contacted his private insurance and told them that it is for denied treatment? I would go up the latter.

As California Help says, your husband's insurance is not going to be willing to take over an obligation that your work comp insurance is supposed to be taking care of (ie if the work comp medical is still open). However, if your work comp medical is settled, that's a different situation and your husband's insurance should cover your future work injury care per the ACA rules. Check with your state's Department of Insurance on this so you know for sure, and what to do if they won't cover.

If your work comp medical is still open and the work comp carrier is denying treatment or denying body parts, then your husband's insurance should be covering that, though they might resist and you might have to force the issue. Talk to your state's Department of Insurance about this and what to do.

Your husband's insurance is a contract and they are obligated to take care of your husband and you. They are not considered primary for the work injury but they are supposed to pay for the care you need if your primary insurance is not. It is then the right of your husband's insurance to try to collect from your negligent work comp carrier. I suspect you would need to be able to show that you have tried to get care through work comp but have been denied reasonable care. This scenario is called subrogation.

The situation is no different than if you are in a car accident with the other person at fault, but their insurance is not paying. Your own auto insurance policy is a contract to take care of you. Your auto insurance can then try to get reimbursed by the other insurance.
(07-21-2018, 06:59 PM)tbear6410 Wrote: He's in between insurance now..  Just started a new job..  He's on that Obama Carp...  I had 2 procedures denied by comp... and did send that in to Medicare.. they denied it too...  They told me point blank.. they will not cover a comp procedure unless I close my medical out and use that money first..

It's not clear from your post whether requests for the procedures were denied or if you had the procedures done but your husband's insurance (and also Medicare) refused to pay the doctors.

What were the reasons each gave for the denial? Had you previously tried to get the procedures done through work comp and were denied, or did you go straight to your husband's insurance? Medicare may have denied because your husband's insurance is primary to Medicare.

If your work comp medical is still open, you cannot expect your husband's insurance to cover work injury care unless you can show them (ie denial letters) that you tried to get the care through work comp but were denied for BS reasons.

There may also be criteria with your husband's insurance that prevented them covering such as deductibles not yet met, non-FDA approved procedures (eg Botox is only covered for certain diagnoses such as migraine), or types of care not covered by the insurance (perhaps such as acupuncture).

Hopefully some of my information might help you in getting proper care.
I called the number Shadow provided and was transferred to tis number 855-854-0429. It was a little difficult and I had to state I was a patient advocate calling to help a member with understanding his coverage. She said with a closed workers' compensation claim you can use their insurance. This is the same thing my private insurance told me and also Kaiser told me as another post stated their insurance was Kaiser, and I did the same thing and called Kaiser. Anyone can call the number I listed and say you are helping a member with their benefits and ask this same question.

The information above in the link saying they do not cover WC injuries is for open workers compensation claims.

If a person has a denial for a work related treatment and their private insurance or Medicare is refusing to cover it I recommend going above that person and file an appeal. They will only cover it if it is something that would have been covered by them. If Medicare is secondary to private insurance I think it will be extremely difficult if you do not get approval by private insurance as they are secondary. There is info on Medicare website about denied treatment in the work comp system and how to request Medicare cover it on conditional payments (like a lien).
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
I have no idea how Medicaid works. It is income based so a settlement may affect ability to receive it.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.

Forum Jump:

Browsing: 1 Guest(s)