Future Medical Expense Projection Worksheet

FUTURE MEDICAL EXPENSE PROJECTION WORKSHEET

Case Name: [________________________________]
Case/Claim Number: [________________________________]
Date of Injury: [__/__/____]
Date Prepared: [__/__/____]
Prepared By: [________________________________]

SECTION 1: CLAIMANT INFORMATION

Name: [________________________________]
Date of Birth: [__/__/____]
Age at Injury: [____]
Current Age: [____]
Gender: [________________________________]
Address: [________________________________]
City/State/ZIP: [________________________________]

SECTION 2: LIFE EXPECTANCY DATA

Standard Life Expectancy Tables:

Source Used:
☐ U.S. Life Tables (CDC/NCHS)
☐ Social Security Administration Period Life Table
☐ State-Specific Mortality Tables
☐ Industry-Specific Tables
☐ Other: [________________________________]

Adjusted Life Expectancy (if applicable):

☐ Life expectancy reduced due to injury
☐ Life expectancy unchanged
☐ Life expectancy determination pending

Remaining Life Expectancy Used for Calculations: [____] years

SECTION 3: INJURY AND TREATMENT SUMMARY

Primary Diagnosis:

[________________________________]
ICD-10 Code: [________________________________]

Secondary Diagnoses:

1. [________________________________] (ICD-10: [________])
2. [________________________________] (ICD-10: [________])
3. [________________________________] (ICD-10: [________])

Current Treatment Status:

☐ Active treatment ongoing
☐ Reached Maximum Medical Improvement (MMI)
☐ Permanent disability established
☐ Degenerative condition expected

Date of MMI (if applicable): [__/__/____]

SECTION 4: FUTURE MEDICAL NEEDS BY CATEGORY

A. Physician/Specialist Visits

B. Therapy Services

C. Prescription Medications

D. Future Surgical Procedures

Adjusted Cost = Estimated Cost × Probability

E. Diagnostic Testing

F. Durable Medical Equipment (DME)

G. Medical Supplies

H. Home Health Care

I. Facility Care (if applicable)

SECTION 5: MEDICAL INFLATION ADJUSTMENT

Medical Inflation Rate Selection:

☐ Consumer Price Index - Medical Care (CPI-M)
☐ Personal Consumption Expenditures Health Care (PCE)
☐ Medical Care Services Index
☐ Custom Rate: [____]%

Selected Annual Medical Inflation Rate: [____]%

Historical Reference:

• Average CPI-Medical (10-year): approximately 3.0-4.0%
• Medicare Trustees assumption: approximately 4.0-5.0%

SECTION 6: NOMINAL FUTURE MEDICAL COSTS

Year-by-Year Projection (First 10 Years):

Summary by Decade:

SECTION 7: FUTURE MEDICAL EXPENSE SUMMARY (NOMINAL)

SECTION 8: PRESENT VALUE CALCULATION

Discount Rate Selection:

Jurisdiction Requirement:
☐ No statutory rate specified
☐ Statutory rate: [____]% (State: [____])
☐ Market-based rate required

Selected Discount Rate: [____]%
Basis for Selection:
☐ U.S. Treasury Rate (Current: [____]%)
☐ High-grade Municipal Bond Rate
☐ State-mandated Rate
☐ Net Discount Method (Discount Rate minus Medical Inflation)
☐ Other: [________________________________]

Net Discount Rate Calculation (if applicable):

Present Value Calculation:

SECTION 9: EXPERT OPINION SUMMARY

Medical Expert:

Expert Name: [________________________________]
Specialty: [________________________________]
Date of Examination: [__/__/____]
Report Date: [__/__/____]

Key Opinions:
☐ Treatment plan attached
☐ Prognosis documented
☐ Life expectancy opinion provided
☐ Causation opinion provided

Life Care Planner (if applicable):

Planner Name: [________________________________]
Credentials: [________________________________]
Report Date: [__/__/____]

Economist (if applicable):

Economist Name: [________________________________]
Report Date: [__/__/____]
Discount Rate Used: [____]%
Present Value Conclusion: $ [________________]

SECTION 10: DOCUMENTATION CHECKLIST

☐ Medical records (all treating providers)
☐ Medical expert report
☐ Life care plan (if applicable)
☐ Economist report (present value)
☐ Life expectancy tables/analysis
☐ Pharmacy records
☐ DME invoices/estimates
☐ Home health care estimates
☐ Medical literature supporting projections
☐ Current cost data sources

SECTION 11: NOTES AND ASSUMPTIONS

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

CERTIFICATION

I certify that this projection is based on available medical records, expert opinions, and reasonable assumptions regarding future medical needs. This worksheet is for settlement calculation purposes and actual future costs may vary.

Signature: ________________________________________ Date: [__/__/____]

Print Name: [________________________________]

Title: [________________________________]

SOURCES AND REFERENCES

• CDC/NCHS U.S. Life Tables
• Social Security Administration Period Life Tables
• Bureau of Labor Statistics CPI-Medical Care
• Physician Life Care Planning: https://www.physicianlcp.com
• The Knowles Group: Future Medical Expense Valuation

This worksheet is provided for informational purposes only. Future medical expense projections require qualified medical expert opinions and economist analysis. Legal counsel should be consulted regarding applicable law and evidentiary standards.