Legal Question in Insurance Law in California

I live in California. I have an underinsured motorist claim against my insurer. My medical bills amounted to more than $24,000.00. I settled my claim against the other party for policy limits of $15000.00 and also got medical payments of $5000 from my own insurance. I asked for 3 times the medical bills under my underinsured coverage (limit: $25K) just to push them to offer policy limits without deducting the 15K I got from the other insurance and the 5K I got for medpay. Now, the adjuster for the underinsured claim is saying that he will not process my claim until he sees the Medicare bill and a denial letter from Medicare for not paying one of my medical bills (I planned on dealing with this bill on my own). What I would like to know is 1.) I know there are offsets for certain items, but can I not have them waive the offset for medpay?, 2) Is my own insurance required to have Medicare on the settlement check? (the third party did not put medicare on the check) and 3) Why does the adjuster need to see the amount of medicare bill to calculate settlement? Is the settlement based on the actual medical bills or can the settlement amount be reduced based on the reduction by medicare? Please provide legal codes, etc. Thanks for the help.


Asked on 12/07/10, 8:02 pm

2 Answers from Attorneys

Medicare is entitled to reimbursement out of your settlement and insurance. Also medicare pays doctors less than they otherwise charge. Your insurance is entitled to factor Medicare into their payments to you.

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Answered on 12/13/10, 1:14 pm
Rivers Morrell Law Firm of Rivers J. Morrell III

To answer question no 1, that depends on the value of the claim, and I cannot answer that based on what you have said. But in general, the UIM carrier gets a full offset from what the negligent party's insurance company pays, in your case $20,000. Any insurance company that is going to pay, is entilted to know the claim, if any, of Medicare/MediCal. You or your attorney are required to notify Medicare. In general you should try to get a letter from Medicare as to the amount of their claim, so you don't have just one check issued. You have them issue two checks, one to you for your claim, and another to Medicare for the amount of their claim. This is a lot easier. For question no. 3, first they are entitled to know the amount, so whether they base their value on this or not, is not the point. They are probably figuring what are the paid amount of the medical bills, and trying to figure out what you are going to net after all of the bills are paid. But in general injuries are evaluated based on the injury, the medical bills, and the residuals.

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Answered on 12/13/10, 3:48 pm


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