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Legalease, Lawyer
Category: Employment Law
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Experience:  13 years experience in employment law, unions, contracts, workers comp law
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Final hearing on NYS Workers compensation settlement section

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Final hearing on NYS Workers compensation settlement section 32 was approved by judge. Including in this final settlement was Medicare set aside for future injury related cost. One month before hearing I received 1st Social Security Disability check. Unknown to me Social Security automatically enrolled me in Medicare with a monthly premium charge that I couldn't afford so I opted out. This leaves me only on Medicare Part A. I was officially opted out 3 weeks before the final hearing. 5 Days after the hearing I received a letter the lawyers representing the insurance co. wishing to withdraw the approved agreement. On what grounds did they pull it off the table? What are my next options in getting the approval? Is this just a stall tactic on their part? Do I have to renigotiate this from beginning? Does Medicare have to reapprove? Thank You
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Customer: replied 4 years ago.

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Hello there


I apologize for the delay in responding to this question but this is the first time I have seen it. I have significant experience in NY (I practiced there for about 5 years) and with worker's compensation cases. I can tell you straight up without hesitation that the insurer has withdrawn the offer because of your pulling out of the Medicare Part B benefits. You see, Medicare Part A pays for just hospitalizations -- it is the Medicare Part B that pays for your medical appointments and medical equipment and anything that you would do or use outside of a hospital setting for your injuries and illnesses. So, when you worked out the settlement with the insurance company, they were assured that you had medical coverage for doctor appointments and other needed medical items through Medicare Part B and that this coverage was to cover you for all of your medical needs for the rest of your life (or the amount of time that you remain disabled enough to continue collecting social security disability which most likely will be the rest of your life). When you cancelled the Medicare Part B, you were cancelling your medical coverage not only for all of your illnesses and injuries but you were also cancelling it for any medical appointments or items that you might need in the future for the injury that you suffered on the job that was the basis for this worker's compensation claim. The reason why this is so troublesome to the worker's compensation insurance carrier is the NY worker's compensation law requires that the employer and/or the insurer pay for medical coverage for that worker;s compensation injury for the rest of your life. However, it is perfectly acceptable for the WC insurer to require that you accept Medicare Part B as part of your social security disability payments before they will settle the claim with you for a lump sum benefit. Because, even if you settle for a lump sum benefit at this time for the WC case, the medical benefits part of your WC claim will remain open and if you have any medical expenses to do with that portion of your body at any point from now until the time you die, the WC insurance company is LEGALLY required to pay for those medical expenses or reimburse you for those medical expenses if you pay them out of pocket. If you have Medicare Part B then the US federal government's medical insurance program will pay for up to 80% of all of the medical expenses that you incur from this work related injury for the rest of your life, and the insurance company can and will be held responsible only for the other 20% of medical bills that Medicare Part B does not pay for. So, it is a complicated situation but the Workers Comp insurer found out that you elected NOT to take the Medicare Part B benefits and that exposes them to paying for 100% of all of your medical bills for your injury and the injured part of your body until you die --- it was a requirement of your settlement from The WC insurer that you would elect and receive Medicare Part B benefits and because you have refused to do that, then they have stopped the settlement from happening. Yes, you have probably put yourself in the position of having to renegotiate the settlement with the WC insurance company and Medicare may also have to approve any new settlement that you come up with -- but you are entitled to question this settlement in the regards XXXXX XXXXX why YOU must pay the full premium for Medicare Part B every month to cover your medical expenses when the WC insurer is legally required to pay for the medical bills anyway and perhaps you might be able to negotiate a little bit higher of a settlement from them if they are requiring that you take and pay for the Medicare Part B benefits --- because doing so will benefit the WC insurance company in the long run when it no longer has to pay the bulk of your medical bills for that injury or that part of your body.


I hope that explanation helps and was clear enough to understand (it is not an easy subject to explain the interplay between SSA and worker's comp insurers). Please let me know if you have further questions. If not, can you please press the 3rd, 4th or 5th smile face below - under this ANSWER box - so I will be paid for my time? I am paid NOTHING unless you press a positive rating below (I do not receive a paycheck and this is not a hobby for me -- it is how I earn a living in a bad economy). Pressing the 3rd, 4th or 5th smile face below will not cost you additional money -- it simply acts as a trigger to Just Answer to pay me for my time. THANK YOU VERY MUCH !!!



Customer: replied 4 years ago.

But what I'm not understanding is that in the Settlement Agreement it Specifically stated that I had to opt out of Medicare!!! Judge also asked if I in fact have done that, Yes! Isn't that why in the agreement their is a set aside amount?

Hello again


Typically a "medicare set aside" in a worker's compensation settlement means that you are supposed to accept the medicare Part B and the amount of money that is in the "set aside" amount is what is to be used to pay for those premiums in order to let the insurance company off the hook for the full cost of your medical treatment - so there is definitely something wrong here and I believe that the judge and the insurance company provider have gotten their wires crossed regarding exactly what the term means. It seems that the judge believes it is one thing and the insurance company believes it is another thing. Unless, of course, the WC insurer's withdrawal has nothing to do with any of this and it could be a completely different reason than what we are discussing now. You did say that you are uncertain what the reason is at this point but believe it has something to do with the medicare because you opted out of it before the settlement was finalized (you can opt back into it in the future at certain times of the year and they may even let you do it now if you must because of this settlement issue). I suggest that you find out exactly what their reasoning is -- it could be something simple in which case there will not have to be any further negotiations - just clarification. It is unusual for an insurer to pull out of a settlement that late after a judge has already approved it and if this is a tactic then I have not seen an insurer use this tactic (deliberate delay at this late date after an agreement is reached for no real reason will just annoy the judge).

Legalease, Lawyer
Category: Employment Law
Satisfied Customers: 16379
Experience: 13 years experience in employment law, unions, contracts, workers comp law
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