My husband was injured as a pedestrian 20 years ago by a motorcycle. There was a long drawn out law suit and he was rewarded with a sum of money.. He is experiencing sciatica in the area of the body where he was hit. Now one spine place is saying that they can't treat him because of this on his records. Does this mean he can only get treatment if he pays out of pocket? Is it worth trying to contact Medicare? It seems wrong that 20 years after an injury he can presently be denied..I would appreciate any expert advice regarding this situation.
When someone receives a personal injury settlement, part of that money may be earmarked for future medical care related to the injury. Medicare is considered the “payer of last resort,” which means it won’t pay for treatment if settlement funds were designated for that purpose. This is often managed through a Medicare Set-Aside (MSA), though not everyone has one.
Medicare decides whether a condition is related to a prior injury by reviewing the original settlement documents, medical records, and diagnosis codes submitted with current claims. If the new condition—such as sciatica—affects the same area as the original injury, Medicare may assume it’s related.
However, many people develop sciatica for unrelated reasons such as aging or degenerative changes. If Medicare denies coverage, it’s possible to appeal the decision with evidence showing the new symptoms aren’t connected to the old injury.
Here are steps you can take:
1. Consult an attorney familiar with Medicare and injury settlements (not just a personal injury lawyer).
2. Gather old and new medical records showing the nature of the injury and current diagnosis.
3. Ask the doctor to explicitly document whether the new sciatica is or isn’t related to the prior trauma.
4. File an appeal with Medicare, including the medical evidence.
I hope this helps.
The old insurance settlement included a percentage of "future medical" expenses - the insurance company paying a portion of her ongoing medical expenses for consequences of the accident. They were thus the "primary insurance" for related claims - they paid a percentage of the claim first and then her employer insurance paid. Over time the accident insurance company paid less and less until the amount they paid made it pointless to even try to collect at all from them. Providers switched to billing the employer insurance directly and things were fine.
BUT, when she went on Medicare, this insurance was somehow still or again on her record as "primary" for related conditions and she was stuck in a limbo where providers wouldn't deal with billing a non-responsive primary insurer first, and Medicare wouldn't pay anything until the primary insurer had paid its portion.
It took weeks of phone calls and emails to get the current owner of the accident claim to send a letter to Medicare saying that they (the accident insurance company) had been released from all liability for this injury. A few weeks later, Medicare sent a letter to us saying they'd received this and would now pay claims.
A: Yes, Medicare can treat a medical issue related to a court case, but a settlement may affect ongoing or future treatment if the settlement includes future medical costs. Medicare will have a right to be reimbursed for any "conditional payments" it made for your accident-related medical care. Additionally, if the settlement covers future medical treatment, a portion may need to be set aside in a Medicare Set-Aside (MSA) account to ensure that Medicare does not pay for future care that the settlement is intended to cover.
How it works
Reimbursement for past care: Medicare has an automatic right to be repaid for any medical bills it paid for that are related to the accident that led to the court case.
Future care costs: If a settlement includes money for future medical treatment, you are required to use that money to pay for your future care before Medicare will pay for it.
Medicare Set-Aside: To protect your future Medicare coverage, you may be required to set aside a portion of your settlement in an MSA account for future medical expenses.
Requirement: This is often required for workers' compensation settlements and may apply to third-party settlements, especially if the gross settlement is over a certain amount (e.g., $25,000 or $75,000).
Purpose: An MSA ensures that the settlement money is used for your future care and that Medicare is not paying for it.
Improvement Standard: Recent court cases, such as the Jimmo Settlement, have reinforced that Medicare can cover services like skilled nursing and therapy for maintenance or to slow decline, not just for improving a patient's condition.
What you should do
Consult with a lawyer: It is highly recommended to work with an attorney who is experienced with injury settlements and Medicare regulations to navigate the process and protect your benefits.
Submit settlement information: You must submit the final settlement details to the Centers for Medicare & Medicaid Services (CMS).
Contact the right people: If you have questions about your benefits, contact 1-800-MEDICARE or your specific Medicare plan.
Seek help from SHIPs: For free, personalized health insurance counseling, contact your local State Health Insurance Assistance Program (SHIP).
I would definitely consult with an attorney who has experience in this area first.
Please tell us what TESTS were run. Has there been xray, MRI? Has anyone indicated to you that whatever is going on is DUE to arthritis from an old injury and is not truly treatable. Because not every ache and pain in aging is.
There has to be more here--something we are missing. Hope to be updated when you get more information.
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