Medical Malpractice Settlement Agreement (Nebraska)

MEDICAL MALPRACTICE SETTLEMENT AGREEMENT AND RELEASE

(Nebraska — Hospital-Medical Liability Act Claim)

1. PARTIES

2. RECITALS

2.1 Claimant alleged that, on or about [DATE OF INCIDENT: __/__/____], Released Provider rendered medical care at [FACILITY] that fell below the standard of care, causing personal injury (the "Incident").

2.2 Claimant [filed / threatened to file] a claim under the Nebraska Hospital-Medical Liability Act, Neb. Rev. Stat. § 44-2801 et seq., styled [CASE CAPTION / Claim No.].

2.3 ☐ A Medical Review Panel was convened (Neb. Rev. Stat. § 44-2840) and rendered an opinion on [DATE]. ☐ Panel review was waived in writing.

2.4 ☐ Pleadings were certified by counsel pursuant to Neb. Rev. Stat. § 25-21,182 (attorney certification of good-faith basis for assertions of fact and law).

2.5 Released Provider denies liability. The parties wish to compromise the disputed claim to avoid further litigation expense and risk.

3. SETTLEMENT CONSIDERATION

3.1 Total Settlement Amount: $[____] (the "Settlement Amount"), paid as follows:

3.2 Statutory Cap (Neb. Rev. Stat. § 44-2825). The parties acknowledge that for acts of malpractice alleged to have occurred on or after December 31, 2014, total damages recoverable from all defendants are capped at $2,250,000 per claimant (acts between Dec. 31, 2003 and Dec. 31, 2014: $1,750,000; acts between Dec. 31, 1992 and Dec. 31, 2003: $1,250,000). The Settlement Amount is within the applicable cap.

3.3 Allocation. The Settlement Amount is allocated as follows for tax and lien purposes:

3.4 Payment Timing. Within [30] days after the later of (a) execution by all parties, (b) court approval (if minor or wrongful-death), and (c) lien resolution per Section 5, Insurer shall pay the Insurer portion. Fund disbursement follows Department of Insurance approval procedures.

3.5 ☐ Structured Settlement. Periodic payments per Schedule A funded by qualified assignment under IRC § 130.

4. RELEASE

4.1 General Release. Claimant releases and forever discharges Released Provider, Insurer, the Fund, and their respective officers, directors, employees, insurers, successors, and assigns (collectively, "Released Parties") from all claims, demands, causes of action, damages, costs, and expenses, known or unknown, accrued or to accrue, arising out of or related to the Incident.

4.2 Covenant Not to Sue. Claimant shall not commence or maintain any action against the Released Parties arising from the Incident.

4.3 No Admission. This Agreement is a compromise of disputed claims; nothing herein is an admission of liability or wrongdoing.

5. LIENS, SUBROGATION, AND GOVERNMENT-PAYOR INTERESTS

5.1 Medicare Secondary Payer (42 U.S.C. § 1395y(b)(2)). Claimant warrants disclosure of all conditional payments. Final demand from CMS / BCRC dated [DATE] in the amount of $[____] has been ☐ paid ☐ escrowed at closing.

5.2 Medicaid. Claimant shall satisfy any Nebraska Department of Health and Human Services Medicaid lien (Neb. Rev. Stat. § 68-919) prior to disbursement.

5.3 ERISA / Private Health Plan / Hospital Liens. Itemized in Schedule B and resolved at closing.

5.4 Indemnification. Claimant and Claimant's counsel jointly indemnify the Released Parties against any future lien claim arising from the Incident.

6. NPDB REPORTING

6.1 The Insurer (or other paying entity acting on behalf of a practitioner) shall report this payment to the National Practitioner Data Bank within 30 days as required by 42 U.S.C. § 11131 et seq. and 45 C.F.R. Part 60.

6.2 Released Provider may submit a Subject Statement to the NPDB. Claimant shall not interfere with required reporting; nothing in this Agreement waives statutory reporting obligations.

7. CONFIDENTIALITY

7.1 The terms of this Agreement, including the Settlement Amount, are confidential. Permitted disclosures: (a) to attorneys, accountants, tax preparers, and insurers on a need-to-know basis; (b) as required by law, including NPDB reporting, court order, subpoena, and tax filings; (c) to the Nebraska Department of Insurance and Excess Liability Fund administrator; (d) to lienholders to effect lien resolution.

7.2 Neither party shall disparage the other regarding the Incident.

8. COURT APPROVAL / SPECIAL CIRCUMSTANCES

☐ Minor Claimant. Approval required under Nebraska law; petition for approval to be filed in [County] County District Court. A guardian ad litem ☐ has been ☐ will be appointed.

☐ Wrongful Death (Neb. Rev. Stat. § 30-810). Personal representative executes on behalf of beneficiaries; allocation among beneficiaries set in Schedule C; court approval obtained.

☐ Special-Needs Trust. Funds to be placed in SNT to preserve Medicaid/SSI eligibility.

9. TAX TREATMENT

9.1 The portion allocated to personal physical injuries and physical sickness is intended to be excluded from gross income under IRC § 104(a)(2). Amounts allocated to lost wages, punitive damages (if any), or interest are taxable.

9.2 No party provides tax advice; each party shall consult independent tax counsel.

10. REPRESENTATIONS AND WARRANTIES

10.1 Claimant has reviewed this Agreement with counsel of Claimant's choice, understands its terms, and signs voluntarily.
10.2 Claimant has legal capacity and authority to settle and release.
10.3 No assignment of any portion of the claim to any third party other than disclosed lienholders.
10.4 Statute-of-limitations period under Neb. Rev. Stat. § 44-2828 (two years, with discovery extensions) has been considered and timely action taken.

11. DISPUTE RESOLUTION

11.1 Governing law: Nebraska.
11.2 Venue: State courts of [County] County, Nebraska, or the U.S. District Court for the District of Nebraska.
11.3 Prevailing party in enforcement may recover reasonable attorney fees.

12. GENERAL PROVISIONS

Entire agreement; written amendments; severability; counterparts; electronic signatures; binding on heirs, executors, administrators, successors, and assigns.

13. EXECUTION

Notary (Claimant): State of Nebraska, County of [____]. Subscribed and sworn before me on [__/__/____]. ___________________ Notary Public.

SCHEDULE A — Structured Settlement Terms

Periodic payment schedule, annuity issuer, assignment company, beneficiaries.

SCHEDULE B — Liens and Subrogated Interests

Medicare (final demand), Medicaid, private health plan, hospital, workers' comp.

SCHEDULE C — Wrongful-Death Beneficiary Allocation

Beneficiaries under Neb. Rev. Stat. § 30-810 and allocation percentages.

SOURCES AND REFERENCES

• Nebraska Hospital-Medical Liability Act, Neb. Rev. Stat. § 44-2801 et seq.
• Neb. Rev. Stat. § 44-2825 (total damages cap — currently $2.25M for acts on/after Dec. 31, 2014).
• Neb. Rev. Stat. § 44-2828 (statute of limitations); § 44-2840 (Medical Review Panel; Excess Liability Fund).
• Neb. Rev. Stat. § 25-21,182 (attorney certification of pleadings).
• 42 U.S.C. § 11131 et seq.; 45 C.F.R. Part 60 (NPDB reporting).
• 42 U.S.C. § 1395y(b)(2) (Medicare Secondary Payer); Neb. Rev. Stat. § 68-919 (Medicaid lien).
• IRC § 104(a)(2); § 130 (qualified assignment).
• Nebraska Department of Insurance, Medical Malpractice / Fund-Qualified Provider Guidelines.

Disclaimer: Informational template only. Verify the operative date of the alleged malpractice against the tiered cap in § 44-2825; confirm Released Provider's qualified status with the Nebraska Department of Insurance; resolve all Medicare/Medicaid liens before disbursement.