Your workers’ compensation case may affect other benefits you are receiving or may become entitled to. Likewise, those benefits may have an impact on your workers’ compensation case. This is a brief summary of issues that may have a bearing on an employee’s workers’ compensation case. An employee is urged to pay attention to these circumstances, especially when considering a settlement of his or her case.
Unemployment Compensation Benefits
Section 287.170.3 RSMo states: “An employee is disqualified from receiving temporary total disability during any period of time in which the claimant applies and receives unemployment compensation.” Therefore, if you receive temporary total disability benefits under the workers’ compensation law (i.e., weekly or bi-weekly checks while the doctor has you off work), and you also receive unemployment compensation benefits for the same time period, you will be required to pay back the temporary total disability benefits.
Many injured workers who qualify for medical benefits under the workers’ compensation law may also be covered by Medicare or may be covered by Medicare in the future.
Under federal law, Medicare is a “secondary payer” in many circumstances, including workers’ compensation cases. In order to protect Medicare’s potential interests, the Centers for Medicare & Medicaid Services (also known as “CMS”), a federal agency, should be notified about a potential workers’ compensation settlement in certain instances. CMS must be notified before a settlement is presented to an administrative law judge for approval. In many circumstances, CMS may require that a Medicare Set-Aside Trust be established and approved before going forward with any workers’ compensation settlement. It may take many months for CMS to decide whether, and under what circumstances, to allow the settlement to proceed.
CMS should be notified under the following circumstances:
- If the injured party is currently on Medicare, either by reason of age or Social Security Disability, AND the amount of the settlement is $25,000 or more; or
- If the injured party is not currently eligible for Medicare but may qualify for Medicare benefits, by reason of age or Social Security Disability, within thirty months of the date of the settlement AND the amount of the settlement is $250,000 or more.
If the settlement is approved without CMS’s review, the employer or insurer may be required to reimburse Medicare for future medical care to the injured party or Medicare can refuse certain benefits in the future to the injured party.
Other important considerations:
- The Administrative Law Judges cannot contact CMS. The parties and their lawyers are responsible for contacting CMS.
- As CMS may require many months to complete its review, settlements may be delayed. It is important to get CMS involved early on in the case to avoid long delays.
- The Administrative Law Judges have no control over the speed or the results of CMS’s review.
- If you are awaiting CMS’s review and have not filed a formal Claim for Compensation in your workers’ compensation case, you need to do so, to avoid the running of the statute of limitations.
For additional information, see the following websites:
Social Security Disability Benefits
If you believe that you are unable to return to any type of work, then, in addition to your workers’ compensation claim, you may wish to apply for Social Security disability benefits.
You can apply for Social Security disability benefits at any Social Security office. You may also apply online at www.ssa.gov. You can call 800-772-1213 for the location of the nearest office, or find it at www.ssa.gov.
If you are thinking about applying for Social Security disability benefits, if you have applied for Social Security disability benefits, or if you are already receiving Social Security disability benefits, you should know that any disability payments you receive from your workers’ compensation case (even from the Second Injury Fund) may reduce your Social Security disability benefits either now or in the future. There is a way to potentially reduce or eliminate the impact of the workers’ compensation settlement on your Social Security disability benefits. This can be accomplished by adding certain language to the settlement stipulation, or by adding an addendum to the settlement stipulation containing this language. This language must be included in the settlement at the time it is approved to be effective. If you have a lawyer, your lawyer should include this language in the settlement stipulation.
If you do not have a lawyer, then you should raise this question to the Administrative Law Judge before agreeing to any settlement. The Administrative Law Judge may raise the question if you do not, but it is not the judge’s responsibility to do so.
There are different burdens of proof for Social Security disability and permanent total disability under the Missouri workers’ compensation law. Qualification under one of them does not guarantee qualification under the other.
Subrogation Rights Against Employee’s Liability Claim
When a third person is liable to the employee for a work-related injury (or to the employee’s dependent survivors for a work-related death), the employer and its workers’ compensation insurer may be entitled to share in any settlement or recovery the employee or dependents may be entitled to receive. This is called a “right of subrogation” and is governed by Section 287.150 RSMo. This means that if you receive any workers’ compensation benefits and also have a liability claim for the same injury, you cannot keep all of the money from the settlement or recovery in the liability claim; some portion of the settlement or recovery must be repaid to your employer or its workers’ compensation insurer.
Mo HealthNet Payments
If, after your work-related injury, you received any medical treatment that was paid for by Mo HealthNet, you may be required to reimburse Mo HealthNet out of your workers’ compensation settlement.
Child Support Obligations
If you are behind on child support obligations, the workers’ compensation insurance company is required by law to pay a portion of your workers’ compensation benefits (whether paid weekly, bi-weekly, or as a lump sum) to the persons or entities to whom the child support is owed.
Missouri’s Second Injury Fund
If an employee had a serious injury or disability before his/her on-the-job injury, the employee may be entitled to benefits from the Second Injury Fund. To obtain benefits from the Second Injury Fund, an employee must file a claim for compensation against the Second Injury Fund. There is also a complicated statute of limitations which governs when a claim must be filed against the Second Injury Fund; settlement of your workers’ compensation case before filing a claim against the Second Injury Fund may jeopardize your Second Injury Fund claim. For more information, please read How the Second Injury Fund Can Help You on this website, or consult with a lawyer.
Understand Your Rights and Obligations: You Have the Right to Consult With A Lawyer
If you have any questions about these issues, you may consult with a lawyer. If you are unable to locate a lawyer who practices workers’ compensation law, you may wish to contact the Missouri Bar Lawyer Referral service at 573-635-3635, the St. Louis Metropolitan Bar Lawyer Referral Service at 314-621-6681, the Springfield Metropolitan Bar at 417-831-2783.
It should not cost you anything to consult a lawyer. Lawyers who regularly practice workers’ compensation law offer free initial consultations. For more information, see Obtaining A Lawyer on this website.
Related: Obtaining A Lawyer