My sister with Down Syndrome was injured at her day program...

by Anonymous
(New Jersey)

My sister has Down Syndrome and attends a day program for the disabled (in New Jersey). She slipped and fell on ice at the program and broke her leg. Who is liable to pay for her injuries, and how do we go about getting them to cooperate?

She only has Medicare insurance and the woman who owns the building told us to send her the bills that insurance doesn't cover. Is that the way it is done? My sister needs to go to a rehab facility which Medicare doesn't cover. How do we get this paid by the liability insurance for the day program?

The rehab isn't going to take her without arrangements for payment up front. Also, the woman who owns the building takes days to return calls and then keeps saying she doesn't know what to do and she has to call someone...and then we don't hear from her again until we leave numerous messages.

What can we do? Thanks for any information you can give.

Visitor Question:
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ANSWER for "My sister with Down Syndrome was injured at her day program...":

Anonymous (New Jersey):

If the "day program" takes place on someone's private property then the owner of that property is probably insured for your sister's injuries and resultant medical bills. The insurance they carry is similar to homeowners. That means negligence may not be a factor in the insurance company's decision to pay for your sister's medical bills.

If your sister's fall took place on ice which wasn't located on the day program's property, then there exists a possibility the day program's insurance may not agree to pay the claim. What this may come down to is who, or what entity had "care, custody, and control" of you sister at the time of her injury.

If you are able to show the day program's personnel where negligent in allowing your sister to fall, she may be entitled to reimbursement for an amount slightly more than her medical bills alone.

If in the alternative your sister just fell on some ice and it wasn't anyone's fault, then your sister's claim will have to revert back to the day program's liability insurance policy.

Let's talk about a possible Medicare claim. Your sister doesn't have any legal duty to seek reimbursement for her medical bills from Medicare. If the bills need to be paid immediately and the medical creditors are putting pressure on your sister or her guardian, then you might consider having Medicare pay whatever portion they are responsible to pay. Then the day program's insurance company may reimburse you for the entire amount at a later time.

The woman from the day program also has no legal duty to make an insurance claim. If she doesn't, and continues to ignore you, you can consider filing suit against the day program.

Depending upon the seriousness nature of the injury, and the resultant medical bills, you can always contact a personal injury attorney. Most will not charge any fee for an initial office consultation. You and your sister may be able to get some satisfaction there.

The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from an attorney licensed in your state. Find a local attorney to give you a free case review here, or call (888) 647-2490.

Best of luck,

Judge Calisi

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