Estate of David Charles Respecke

discussion provided as to what the total claim Aitana Santiago Gonzalez could have pursued (or was pursuing) against the defendant. The Court needs the amount of Aitan's claim in order to determine if the reimbursement to Medi-Cal is within the Ahlborn guidelines.

In Camila Santiago Gonzalez's case, the situation is worse. First, Camila's medical expenses ($4,110.46) are almost double that of Aitana's, yet Camila was apportioned only 47% of the amount given to Aitana ($18,394.55). This requires explanation by the Petitioner to ensure the settlement apportionment is fair as it relates to Camila. Second, the allegations in the petition claim that Medi-Cal paid no portion of the $4,110.46 in medical expenses that were actually paid out, but the medical bills submitted in support of the petition show that $3,042.99 billed by CHC was paid by Cen-Cal, a Medi-Cal entity. While it does not appear that Medi-Cal is claiming a lien on Camila's recovery, this issue needs clarification.

According to SCOTUS, DHCS violates federal law when it places a statutory lien on any amount of a settlement or judgment above an amount specifically designated as reimbursement for medical costs. (Arkansas Dept. of Health and Human Services v. Ahlborn (2006) 547 U.S. 268, 272.) Thus, according to California cases decided after Ahlborn, DHCS cannot seek full reimbursement for Medi-Cal payments made for medical care required to treat injuries caused by a third-party tortfeasor, unless the recipient of the medical care recovers the full value of their tort claim. (See e.g. Lopez v. Daimler Chrysler Corp. (2009) 179 Cal.App.4th 1373, 1378; Lima v. Vouis (2009) 174 Cal.App.4th 242, 260; Bolanos v. Superior Court (2008) 169 Cal.App.4th 744, 748.)

Thus in a settlement, DHCS's recovery is limited to a percentage of the portion of the settlement apportioned for reimbursement of payments made for medical care, equivalent to the percent the settlement is to the value of the full claim amount. Expressed mathematically, the Ahlborn formula calculates the reimbursement due as the total settlement divided by the full value of the claim, which is then multiplied by the value of benefits provided. (Reimbursement Due = [Total Settlement ÷ Full Value of Claim] × Value of Benefits Provided.) (