October 23, 2019

What Are the Factors Used in Evaluating a Catastrophic Injury Case for Settlement?

I have been classified Catostrophic by GBWC and am totally disabled. Everyone concerned has no objections. My insurance Co. has said that they may want to settle. Medicare setaside has already benn set. What should I be looking for in a settlement. Is there an amount that I should be looking for . I am 55 and will not be able to work again. My claim is covered by the SITF. , but my Ins. Co. is in rehab. Thanks I look forward to your answers.

Jodi Ginsberg responds:  James, thank you for your email.   Here are my thoughts.

I look at a number of issues when settling a catastrophic workers’ compensation claim.  By the way, since some of those reading this blog entry may not be familiar with the term "catastrophic injury," I would like to briefly define the term.  Under Georgia workers’ compensation law, the State Board has the power to designate a claimant’s injuries as catastrophic.   This means that the Board recognizes that a claimant like James will not likely be able to return to work because of the severity of his injuries. 

Most importantly, once a claim has been deemed catastrophic, the 400 week cap on benefits does not apply.  In theory a catastrophic claimant could collect temporary total benefits for the rest of his life, as opposed to a maximum of 400 weeks for a non-catastrophic claim.  Note, however, that just because a claim has been deemed catastrophic, there is no automatic right to 400 weeks.  In theory a treating doctor could return a catastrophic claimant back to work.

That being said, catastrophic claims have a higher value for settlement purposes since the employer/insurer’s exposure is unlimited.  Also, when a case is deemed catastrophic, a "rehabilitation supplier" is assigned to your case – these case workers are neutral in theory, but usually their interests lie more with the insurer.

Now, back to James’ question.   I go through a checklist to evaluate the value of a catastrophic claim.  My checklist includes factors like:

  • what is the insurance company’s exposure for future temporary total disability – what do the actuarial tables say about your projected lifespan?

  • how much future medical care will you require?

  • what is the likelihood of needing future surgeries?

  • will home modifications be required because of your injuries

  • will vehicle modifications or a vehicle purchase be required

  • will home health care services be needed?

  • what are the provisions of the Medicare Set Aside

  • since the Subsequent Injury Trust Fund (SITF) is involved, and your because the insurer is not fully solvent (the Insolvency pool is involved), timing would be an issue.  My experience has been that the SITF complicates matters because there are layers of bureaucracy involved in getting an SITF case settled

  • what future benefits will Social Security provide for post-settlement living costs

  • would a structure settlement be in your best interest?

  • should you settle in the first place? – sometimes your best bet is to maintain the status quo and continue to receive benefits for a period of months or years

These factors are among the ones that I consider when looking at a catastrophic case.  I can’t really comment more without  knowing about your specific case, but I think you get the idea.  If I can be of service to you, please do not hesitate to call me.

[tags] catastrophic injury and georgia workers compensation, subsequent injury trust fund, medicare set aside, settling a catastrophic georgia workers’ compensation case [/tags]


What is Two Year Old Case Worth in Settlement if I Have Returned to Work?

I was injured in a car accident in Dec. 2004 while on the job. Workers comp accepted responsibility and paid my medical and PT expenses. Extensive injuries included broken femur, broken (upper) arm, fractured liver (which required surgery for continued bleeding), broken ribs, punctured lung, etc. Spent 24 days in ICU. After several months recovery at home, Dr. declared me at 7% disability, and worker’s comp paid several months worth of benefits based on that rating. Now it is 2 years later and while I am able to work, I still have little strength in my arm, and I walk with a limp (and occasionally my leg gives way and I nearly fall). Some days are pretty painful, although I manage to hold down a full-time job. One year ago, they asked if I wanted to settle (not naming a figure) and I declined. Nothing else has been mentioned. Can you give me a vague figure for settlement for these type injuries and also will my time run out for settlement?

Jodi Ginsberg replies:  I look at a number of factors when creating a demand for settlement.  There are two "big picture" concepts that apply:

1) the best time to settle is when there is maximum uncertainty in your case.   Perhaps you are facing surgery, which would mean unknown medical costs and unknown lost wage benefits payable.  Perhaps your doctor is proposing conservative treatment in the form of several months of physical therapy after which possible surgery.  As your lawyer, I can make the argument that the insurance company’s potential financial exposure might be XYZ dollars.  If your doctor has released you back to work or if your doctor has already performed surgery and you are participaing in an uneventful rehabilitation, there is less uncertainty and less reason for the insurance company to value the case at a high number.

2) insurance companies look at their potential financial exposure when deciding how much to offer you in settlement.  They don’t care who you are or what you did.   They are only concerned about money.   If we can convince them that they may be on the hook for hundreds of thousands of dollars, they will offer substantially more than they would if they calculate their exposure at a few thousand dollars.

Here, my biggest concern has to do with the age of your case.  First, you may have a statute of limitations problem.  Second, you would have to link your current problems back to an accident that happened two years ago, despite your return to work.  The insurance company will argue that any current problems may have to do with your post-December, 2004 work (or perhaps non-work) activity.

Returning to work, as you may have guessed, can create issues with settling a case.

They have already paid you PPD (permanent partial disability) so you would need another doctor to give you a higher PPD rating that what you already have.

I think that your case has some settlement value, but perhaps not as much as it would have had in 2005.  If you want to call me to discuss, please feel free to do so.

[tags] workers compensation settlement, ppd rating, ttd benefits, georgia worker compensation [/tags]

Medicare Set Aside Explained

North Carolina trial lawyer Chris Nichols has written a very useful description of how the Medicare Set Aside rules work in workers’ compensation cases.   He also notes that federal law also permits Medicare to pursue Set Asides in liability cases (although Medicare has not yet done this).

Chris describes the concept of a Set Aside as follows:

The concept of the law is that Medicare is a "secondary payer" when any other form of insurance exists to pay claims.  Before 2001, that meant traditional health insurance, but starting in 2001 Medicare began to interpret that to mean that even third party insurance, specifically Worker’s compensation settlements that "cut off" future medical benefits (clinchers), would be subject to the Medicare Secondary Payer regulations. This meant that any Workers Compensation clincher that resaonably cut off future workers compensation benefits would have to be reviewed by CMS to determine if there should be an MSA "allocation."  Accordingly, Medicare would look at the case and decide what the future medical costs for the injury would be.  The future costs would be placed in a MSA trust for the payment of medical services related to that claim.

We frequently have to deal with Medicare in large settlements, and often the Set Aside negotiations can add time and aggrevation to a settlement.  However, Medicare Set Asides are often a fact of life that we must be aware of prior to entering settlement negotiations.

[tags] Medicare Set Aside, Medicare Secondary Payer, Georgia Workers’ Compensation, Workers compensation settlements, Medicare lien [/tags]

No Liability Stipulations Often a Judgment Call

I am frequently called upon by my clients to explain the difference between settling their workers’ comp cases and agreeing to a “no-liability” stipulation.

If the insurance company has paid benefits, paid for medical care and accepted the on-the-job injury claim as compensible, then the only type of settlement permitted is a standard settlement.

On the other hand, if the insurance company has denied (controverted) the claim and not paid benefits, then the case can be settled with either a standard settlement or with a no-liability stipulation. In a no-liability stipulation, the parties agree to disagree. The employer/insurer denies that a compensible accident happened but agrees to pay a lump sum to settle the worker’s outstanding claim for benefits.

Often, my client (the injured worker has a hard) with the concept of a no-liability stipulation. Frequently, the language of the stipulation contains assertions by the employer that the accident did not happen at all. Even if a substantial sum of money is involved, many injured workers have a hard time signing off on a document that essentially says that they are lying.

In my role as the claimant’s lawyer, my focus is on getting my clients enough money and sufficient medical care so that my client can live his life with dignity. Sometimes, as a matter of business, a no-liability stipulation is the best alternative.

A few weeks ago, I settled a case with a no-liability stipulation and I believe that my client is better off with this solution than if we had taken the case to the State Board of Workers’ Compensation and won.

At the time of his accident, my client was a 30 year old man who worked for a poultry processing plant. He was told by his supervisor to clean out a large machine that made filets out of chicken breasts. This machine was a large tube (large enough for a man to fit inside) with sharp blades rotating alongside a conveyor belt that carried the chicken breasts.

My client crawled onto the conveyor belt and started to clean the blades when someone turned the machine on. He tried to pull a manual cut-off rope but the manual cut off did not work. He tried to yell for a co-worker, but the person on watch did not speak English. My client was cut all through his midsection by the sharp blades and suffered a crushed pelvis.

Although there were numerous witnesses to this accident, the insurance company denied coverage on the grounds that my client was engaged in “wilful misconduct.” The insurance company’s adjustor advised me that my client’s supervisor would testify that my client failed to use a magnetic card to turn off the machine himself.

My client and several of his co-workers advised me that no one had ever trained them in the use of the magnetic cards and that the employees were told to sign forms verifying their training – despite the absence of actual training – if they wanted to get paid. So, every month, the employees of this poultry plant signed forms verifying their completion of training courses when no such courses were ever given.

As you might imagine, my client was extremely hurt and upset that his employer was trying to put the blame on him for this horrible accident. His problem, however was that he needed immediate medical care if he hoped to recovery.

I recognized that part of what was motivating the company was a fear of huge liability – not just this workers’ compensation case, but perhaps an OSHA investigation and even criminal negligence charges.

I suggested to the adjustor that rather than firing my client, they keep him on as an employee and cover the cost of his group medical insurance. I pointed out that if they totally cut him off and we ended up winning at a hearing 6 months down the road, they would have a much more disabled person requiring much more intensive and expensive rehabilitation.

The adjustor agreed and the company allowed my client to continue to receive medical care. Six months later, when we went to a mediation, my client was recovering from his injuries and was ready to move on. Our “no-liability” stipulation included $80,000 in cash plus the insurance company agreed to reimburse the health insurance carrier for all medical costs. In addition, the employer agreed to provide COBRA medical coverage to my client at a discounted rate of less than $100 per month.

Was my client made totally whole? No, of course not. His injuries are pemanent and he will never be able to perform certain types of physical activities. He also carries with him some resentment against his former employer for trying to shift the blame for his accident on to him.

However, in this case, the no-liability stip solution made sense for everyone. My client got the medical treatment he needed and avoided the stress of extended litigation. He also got a lump sum of money that will help him cover his bills until his recovery is more complete. Had we taken this case to a hearing we might have won – but then again, the employer was prepared to present testimony and written documentation supporting its position.

After laying out the possiblities, my client decided that the no-liability stipulation was the way to go and I agree with his decision. What do you think?

[tags] no liabilty stipulation, Georgia workers compensation on-the-job injury-georgia workers’ comp mediation [/tags]