Indiana Medical Malpractice Settlement Agreement and Release

INDIANA MEDICAL MALPRACTICE SETTLEMENT AGREEMENT AND RELEASE

This Settlement Agreement and Release ("Agreement") is entered into as of [__/__/____] by and among:

1. RECITALS

1.1 On or about [__/__/____], Claimant alleges that Released Provider rendered medical care that resulted in injury to [Claimant / decedent / minor].

1.2 ☐ A Proposed Complaint for Damages was filed with the Indiana Department of Insurance under Ind. Code § 34-18-8 on [__/__/____], Cause No. [____________], and presented to a Medical Review Panel under Ind. Code § 34-18-10.

☐ A civil action was filed in the [____________] Court, Cause No. [____________].

☐ The parties have agreed in writing under IC § 34-18-8-4 to waive presentation to a Medical Review Panel, and a copy of that waiver is attached as Exhibit A.

☐ The damages sought do not exceed $15,000 and the Medical Review Panel requirement does not apply under IC § 34-18-8-6.

1.3 Released Provider denies liability. The parties wish to resolve all disputes without further litigation.

2. SETTLEMENT PAYMENT AND STATUTORY CAP STRUCTURE

2.1 Total Settlement Amount: $[__________________] ("Settlement Funds").

2.2 Allocation:

2.3 Fund Approval. Any payment from the Patient's Compensation Fund requires (a) payment by Released Provider/Insurer of its maximum liability under IC § 34-18-14-3, and (b) a petition and order under IC § 34-18-15, with notice to the Commissioner of Insurance.

2.4 Payment Terms. Provider/Insurer shall pay its portion within [____] days of execution; the Fund portion shall be paid pursuant to court order under IC § 34-18-15.

3. STRUCTURED SETTLEMENT (Optional)

☐ A portion of the Settlement Funds in the amount of $[__________] shall fund a structured settlement annuity issued by [____________], with payments per Exhibit B. The structure is intended to qualify under IRC §§ 104(a)(2) and 130.

4. RELEASE

In consideration of the Settlement Funds, Claimant fully and forever releases, acquits, and discharges Released Provider, its insurers, employees, officers, directors, agents, partners, affiliates, successors, and assigns (collectively, "Released Parties") from any and all claims, demands, causes of action, damages, costs, expenses, and attorney fees of any kind, known or unknown, arising out of or related to the medical care described in Section 1, including without limitation claims for negligence, gross negligence, lack of informed consent, EMTALA, vicarious liability, loss of consortium, wrongful death (IC § 34-23-1), and survival (IC § 34-9-3).

5. NO ADMISSION OF LIABILITY

This Agreement is a compromise of disputed claims. Released Parties expressly deny any wrongdoing or liability. Settlement payment is not, and shall not be construed as, an admission.

6. NPDB / LICENSING REPORTING

Claimant acknowledges that, under 42 U.S.C. § 11131 et seq. and 45 C.F.R. Part 60, payment made on behalf of an individual licensed practitioner in settlement of a written claim must be reported to the National Practitioner Data Bank by the entity making payment. The parties acknowledge that no provision of this Agreement can alter or prevent this required reporting.

7. CONFIDENTIALITY

7.1 The parties and counsel agree to keep the terms of this Agreement strictly confidential, except as required by: NPDB reporting, court approval, IC § 34-18-15 Fund proceedings, IRS reporting, Medicare/Medicaid reporting, attorney-client communication, licensed financial/tax advisors, and operation of law.

7.2 Permitted public statements are limited to: "The matter has been resolved." Breach entitles non-breaching party to injunctive relief and liquidated damages of $[__________].

8. MEDICARE / MEDICAID / LIEN RESOLUTION

8.1 MSP Compliance (42 U.S.C. § 1395y(b)(2)). Claimant warrants Medicare enrollment status: ☐ Beneficiary; ☐ Not a beneficiary; ☐ Reasonable expectation within 30 months. Claimant has obtained / will obtain a Conditional Payment Letter and Final Demand from CMS/BCRC. Any conditional payments shall be satisfied from the Settlement Funds.

8.2 Medicare Set-Aside (MSA). ☐ MSA not required; ☐ MSA in the amount of $[__________] funded per Exhibit C.

8.3 Medicaid Lien (42 U.S.C. § 1396k; IC § 12-15-8.5). Claimant has notified Indiana Medicaid (FSSA) and obtained a final lien statement, satisfied from Settlement Funds.

8.4 ERISA / Hospital / Subrogation Liens. Identified and resolved in Exhibit D.

8.5 Indemnification. Claimant indemnifies Released Parties against any lien, subrogation claim, or recovery action arising from unreported or unresolved liens.

9. TAX TREATMENT

The parties intend that all amounts attributable to personal physical injuries or physical sickness be excluded from gross income under IRC § 104(a)(2). Allocations (if any):

No party provides tax advice; each party shall consult its own tax advisor.

10. COURT APPROVAL / MINORS / WRONGFUL DEATH

☐ Minor Settlement. Subject to court approval under Ind. Code § 29-3-9-7 and Ind. Trial Rule 17(C); proceeds deposited per court order.

☐ Wrongful Death. Subject to approval under Ind. Code § 34-23-1; allocation among statutory beneficiaries per Exhibit E.

☐ Estate / Incapacitated Adult. Subject to probate / guardianship court approval.

11. DISMISSAL

Within [____] days of receipt of all Settlement Funds, Claimant shall execute and cause to be filed a stipulation of dismissal with prejudice of the underlying action and/or proposed complaint, each party bearing its own costs and fees except as provided herein.

12. ATTORNEY FEES AND COSTS

Each party bears its own attorney fees and costs. Claimant's counsel's fees and case expenses are deducted from Claimant's recovery per Exhibit F.

13. GENERAL PROVISIONS

☐ Indiana law governs; ☐ entire agreement; ☐ no oral modifications; ☐ severability; ☐ counterparts and electronic signatures permitted; ☐ each party acknowledges independent legal advice; ☐ each signatory warrants authority; ☐ Claimant acknowledges sufficient time to consider.

SIGNATURES

NOTARY ACKNOWLEDGMENT

STATE OF INDIANA, COUNTY OF [____________] ss:

Before me, a Notary Public, personally appeared [____________], who acknowledged execution of the foregoing on [__/__/____].

__________________________ Notary Public — My Commission Expires: [__/__/____]

EXHIBITS

• Exhibit A — Medical Review Panel Waiver (IC § 34-18-8-4) (if applicable)
• Exhibit B — Structured Settlement Schedule
• Exhibit C — Medicare Set-Aside Documentation
• Exhibit D — Lien Resolution Schedule (Medicare / Medicaid / ERISA / Hospital)
• Exhibit E — Wrongful Death Beneficiary Allocation
• Exhibit F — Attorney Fee and Cost Disclosure

Sources and References

• Indiana Code § 34-18 — Medical Malpractice Act
• Indiana Code § 34-18-14-3 — Damages Cap ($1.8M total / $500K provider / $1.3M Fund for acts after 6/30/2019)
• Indiana Code § 34-18-8-4 — Medical Review Panel; waiver
• Indiana Code § 34-18-15 — Patient's Compensation Fund procedures
• Indiana Code § 34-23-1 — Wrongful Death Act
• 42 U.S.C. § 11131 et seq. and 45 C.F.R. Part 60 — NPDB reporting
• 42 U.S.C. § 1395y(b)(2) — Medicare Secondary Payer
• 42 U.S.C. § 1396k; IC § 12-15-8.5 — Medicaid lien
• 26 U.S.C. § 104(a)(2) — Tax exclusion for personal physical injury damages

DISCLAIMER: This template is informational only and is not legal advice. Settlements exceeding the provider's $500,000 statutory liability require Patient's Compensation Fund procedures under IC § 34-18-15 and judicial approval. Engage Indiana counsel and qualified Medicare/Medicaid compliance counsel before execution.