There are three ways to finish your case. The 1st way is done by stipulations and an award. The second is a compromise and release. The Third is a Findings and Award
STIPULATIONS AND REQUEST FOR AWARD
A stipulated award sets out an agreed to permanent disability rating and confirms the body parts injured and the need for future medical care. For injuries, prior to 2014 you are also entitled to a job retraining voucher from 4 to 10 thousand dollars depending on your permanent disability rating. This type of settlement allows you to reopen your claim to claim greater disability if your condition worsens within 5 years from the date of injury.
COMPROMISE AND RELEASE
A compromise and release is a one time payment that absolves the insurance carrier from all further liability including medical care. In this type of settlement you are paid compensation for your permanent disability, future medical care and retraining voucher. If you are on medicare you need their approval of the amount paid for future medical care in the settlement. Medicare is what is called a secondary payer. So if any other entity is responsible for payment of the same medical care they will not pay for it. However, if they agree to the amount set aside for future medical care at the time of settlement and you use that amount up then they will take over once it is exhausted. You have duties such as annual reporting to Medicare and you have to keep the money in an interest-bearing separate account. This is a one-time payment unless you desire to set up an annuity with your one-time payment. Attorneys fees are based on the total settlement in this type of settlement.
FINDINGS AND AWARD
The last way to resolve a case is by putting on your evidence and asking a judge to determine the permanent disability rating or to resolve which injured body parts are related to the injury and how badly you are injured. Under this method, you also get a future medical award and voucher for retraining afterward depending on the courts’ findings. This method is appropriate if there is a range of possible findings and the parties cannot agree to an amount.
PERMANENT DISABILITY RATINGS
The permanent disability is assessed by either your primary physician or a qualified medical examiner utilizing the American Medical Associations Guidelines to Permanent Disability. Depending on the body part impairments are assigned by diagnosis or objective measurements. A slight increase of up to 3% can be added for pain. Under a judicial decision referred to as Almarez /Guzman vs WCAB that was later codified by statute, a doctor can analogize to other bodily impairments to provide the most accurate rating.
After an impairment is assigned it is adjusted for causation, ( how much is related to your injury as opposed to a pre-existing condition) age, occupation, and a slight increase based on studies of future earnings losses of similarly situated individuals. Once adjusted, that number is your permanent disability percentage. If the case goes to trial or is stipulated the attorney’s fee is based on the value of the permanent disability typically at 15%.
We then correlate the impairment number to a table contained in Labor Code §4658 which indicates how many weeks of payments you are eligible to receive.
The amount of each payment varies depending on the wage but typically starts at $230 per week and 270 per week for disability ratings over 70%. The higher the percentage the longer weekly payments are made. If the injury occurred prior to 2014, and the employer has more than 50 employees at the time of injury, then the payments will increase or decrease by 15%, depending on whether the employer takes the person back to work or not in a modified position for at least one year. If you have a rating at 70% or above then you are eligible for a life pension pursuant to Labor Code 4659. The pension starts after the weeks of underlying weeks are paid out. The amount it starts at varies depending on the percentage of permanent disability.
After the life pension starts it can be increased on a cost of living basis annually tied to the state’s average wage increases as reported to the Employee Development Department. There is always the possibility of proving you are completely disabled from working anywhere and that pays at the temporary disability rate for life with cost of living increases. However, those cases are extremely difficult to prove and extremely rare. The standard is higher than social security. There are may jobs that are not very physical.
FUTURE MEDICAL CARE
There are potential offsets to social security and medicare if you settle out your medical care. If you have properly advised social security of what you are receiving now then any potential offsets should already be occurring. If you have not already you need to inform them and you may have an overpayment issue.
As for Medicare they are what is called a secondary payer. This means they will only pay for medical care if nobody else is responsible. Medicare is not an issue if you stipulate your case or get a Findings and Award. If you do settle by compromise and release then medicare must approve the amount set aside by the settlement for future medical care. If you settle this way you will need to set aside the approved amount of money to use for your future care and make an annual reporting of the balance and amounts used for medical care. Once the set aside is exhausted then medical will step in assuming you have receipts and properly spent the money for your medical care for your industrial injury.
If you have other insurance that you pay for then still keep receipts of co-pays and other costs. Medicare may only recognize costs that are covered by Medicare or paid at prices paid in workers compensation cases which are typically less than what individuals are charged. If you have not complied with these rules then Medicare will refuse to pay for medical care covered by the settlement until you can prove it was properly exhausted.
The upside is a Medicare set aside settlement puts you in control of your care with no more denials and you receive your money all at once or in annuities if you prefer. If you die prematurely the money is inheritable to your family. Under stipulations, all benefits would stop if you passed away. The safer thing to do is probably keep your medical care unless you are sure you are covered elsewhere.