Medical Malpractice Settlement Agreement and Mutual Release

MEDICAL MALPRACTICE SETTLEMENT AGREEMENT AND MUTUAL RELEASE

(Wisconsin)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation; Mutual Release
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title; Parties

This Medical Malpractice Settlement Agreement and Mutual Release (the "Agreement") is entered into as of [__/__/____] (the "Effective Date") by and between:

(a) [CLAIMANT FULL LEGAL NAME], an individual residing at [ADDRESS] ("Claimant"); and

(b) [HEALTHCARE PROVIDER FULL LEGAL NAME], a [entity type] organized under the laws of Wisconsin with its principal place of business at [ADDRESS] ("Provider").

[Optional: [INSURER LEGAL NAME] and the Wisconsin Injured Patients and Families Compensation Fund join this Agreement solely for purposes of payment and release under Wis. Stat. ch. 655.]

Claimant and Provider are each a "Party" and, collectively, the "Parties."

1.2 Recitals

A. Claimant alleges that medical services rendered by Provider on or about [DATE(S)] caused personal injuries (the "Claim").
B. The Claim is or may be the subject of an action styled [CASE CAPTION], in the Circuit Court for [COUNTY] County, Wisconsin (the "Action"), and/or a request for mediation under Wis. Stat. §§ 655.42–655.58 (the "Mediation").
C. The Parties wish to fully and finally resolve the Claim, the Action, and the Mediation without admission of liability, in compliance with Wis. Stat. ch. 655 and Wis. Stat. § 893.55, including the noneconomic damages cap at Wis. Stat. § 893.55(4)(d)1 upheld in Mayo v. Wisconsin Injured Patients & Families Compensation Fund, 2018 WI 78.

In consideration of the mutual promises herein, the Parties agree as follows.

2. DEFINITIONS

"Action" — as defined in Recital B.

"Claim" — as defined in Recital A.

"Confidential Information" — as defined in Section 5.2.

"Fund" — the Wisconsin Injured Patients and Families Compensation Fund created under Wis. Stat. § 655.27.

"NPDB" — the National Practitioner Data Bank established under 42 U.S.C. § 11131 et seq.

"Noneconomic Damages Cap" — the $750,000 limit on noneconomic damages under Wis. Stat. § 893.55(4)(d)1.

"Released Claims" — as defined in Section 7.2(a).

"Released Parties" — as defined in Section 7.2(b).

"Settlement Amount" — the total monetary consideration under Section 3.1.

"Settlement Payment Date" — the date on which payment is due under Section 3.1.

"Structured Settlement" — as defined in Section 3.2.

3. OPERATIVE PROVISIONS

3.1 Payment of Settlement Amount

(a) Provider (and/or Provider's insurer or the Fund, as applicable) shall pay to Claimant the total Settlement Amount of $[__________] on or before [__/__/____] by [wire transfer / cashier's check] payable to [PAYEE INFORMATION].

(b) The Settlement Amount fully encompasses:
☐ Economic damages (e.g., past/future medical expenses, lost earnings);
☐ Noneconomic damages, subject to the $750,000 cap under Wis. Stat. § 893.55(4)(d)1;
☐ Attorneys' fees and costs;
☐ All statutory liens, subrogation, or reimbursement claims (Medicare, Medicaid, ERISA, Wisconsin BadgerCare, hospital liens under Wis. Stat. § 779.80).

3.2 Structured Settlement (Optional)

If elected:
(a) Provider (or its insurer) shall fund a qualified assignment and annuity contract from an A.M. Best A- or better carrier.
(b) Periodic payments: $[AMOUNT] annually beginning [__/__/____] for [___] years, plus balloon payment of $[AMOUNT] on [__/__/____].
(c) The actuarial present value equals the Settlement Amount.
(d) No acceleration or commutation absent mutual written consent.

3.3 Fund Participation (Wis. Stat. ch. 655)

If Provider is a "qualified health care provider" under Wis. Stat. § 655.002, the portion of the Settlement Amount exceeding Provider's primary coverage limits (currently $1,000,000 per occurrence / $3,000,000 annual aggregate per Wis. Stat. § 655.23(4)) shall be paid from the Fund pursuant to Wis. Stat. § 655.27. The Fund's joinder and approval, where required, are attached as Schedule 3.3.

3.4 Dismissal of Action / Conclusion of Mediation

Within [5] business days after full delivery of the Settlement Amount (or funded Structured Settlement), Claimant shall file a Stipulation and Order of Dismissal with prejudice of the Action under Wis. Stat. § 805.04 and shall withdraw any pending Mediation request, each Party bearing its own fees and costs except as provided herein.

3.5 NPDB and Reporting Obligations

Provider acknowledges that any payment made on Provider's behalf in this matter must be reported to the NPDB by the payer under 42 U.S.C. § 11131 and 45 C.F.R. Part 60, and may be reported to the Wisconsin Medical Examining Board under Wis. Stat. § 655.26 and Wis. Admin. Code Med. ch. 12. Nothing in this Agreement waives or limits any such mandatory reporting obligation; provisions purporting to do so are void as against public policy.

3.6 Conditions Precedent

Payment is conditioned upon:
☐ Execution of this Agreement by all Parties;
☐ Delivery of executed IRS Form W-9;
☐ Lien resolution evidence (Medicare Final Demand or Conditional Payment Letter, Medicaid release, ERISA satisfaction);
☐ Court approval if Claimant is a minor or protected person (Wis. Stat. § 807.10);
☐ Fund approval, if required.

4. REPRESENTATIONS & WARRANTIES

4.1 Authority. Each Party has full authority to execute and perform this Agreement.

4.2 No Assignment. Claimant represents that no portion of the Claim or any Released Claim has been assigned, pledged, or otherwise transferred.

4.3 Liens. Claimant has disclosed all known liens, subrogation claims, and reimbursement obligations on Schedule 4.3 and shall satisfy them from the Settlement Amount. Claimant shall indemnify the Released Parties for any undisclosed lien (subject to applicable Medicare law).

4.4 Capacity. Claimant has read this Agreement, has had the opportunity to consult independent counsel, and executes it voluntarily.

4.5 Survival. Representations survive for [eighteen (18)] months; fraud survives indefinitely.

5. COVENANTS & RESTRICTIONS

5.1 NPDB & Regulatory Reporting. Provider and its insurer/the Fund shall comply with all mandatory NPDB and Wisconsin Medical Examining Board reporting under 42 U.S.C. § 11131, 45 C.F.R. Part 60, Wis. Stat. § 655.26, and Wis. Admin. Code Med. ch. 12.

5.2 Confidentiality. Except as required by law (including NPDB and § 655.26 reporting, court filings, tax returns, and Medicare/Medicaid disclosures), the Parties shall keep the Settlement Amount and terms confidential. Permitted disclosures: counsel, tax advisors, insurers, the Fund, immediate family, and as required by court order or statute.

5.3 Non-Disparagement. Each Party agrees not to make false or defamatory statements about the other concerning the Claim or the Action. Nothing prohibits truthful statements to regulators, courts, or licensing bodies.

5.4 No Admission of Liability. This Agreement is a compromise of disputed claims; Provider denies liability, and no provision constitutes or shall be construed as an admission.

5.5 Notice & Cure. A Party alleging breach shall give written notice and a [10] business-day cure period before exercising remedies under Section 6.

6. DEFAULT & REMEDIES

6.1 Events of Default. (a) Failure to deliver any payment when due; (b) failure to file dismissal within the time set in Section 3.4; (c) material breach of Section 5.2 (Confidentiality).

6.2 Remedies.
(a) Provider Default. Claimant may seek entry of judgment for the unpaid amount plus statutory interest under Wis. Stat. § 138.04 / § 814.04(4), attorneys' fees, and costs.
(b) Claimant Default. Provider may seek dismissal with prejudice, specific performance, and reasonable enforcement fees.

6.3 Attorneys' Fees. The prevailing Party in any enforcement action shall recover reasonable attorneys' fees and costs.

7. RISK ALLOCATION; MUTUAL RELEASE

7.1 Limitation of Liability. Provider's aggregate liability arising from the Claim is limited to the Settlement Amount.

7.2 Mutual Release.
(a) Released Claims. All past, present, and future claims, demands, causes of action, damages, and liabilities, known or unknown, arising out of or related to the Claim, the underlying medical care, the Action, and the Mediation, including all economic and noneconomic damages within the meaning of Wis. Stat. § 893.55.
(b) Released Parties. The Parties and their respective parents, subsidiaries, affiliates, insurers, reinsurers, the Fund, officers, directors, employees, agents, successors, and assigns.
(c) Release. Each Party fully and forever releases the Released Parties from the Released Claims.

7.3 Carve-Outs. The release does not extend to (i) obligations created by this Agreement; (ii) mandatory NPDB or Wisconsin Medical Examining Board reporting; (iii) Medicare/Medicaid rights under federal law; (iv) any criminal proceeding; (v) workers' compensation claims (if separately preserved).

7.4 Tax Treatment. The Parties intend that amounts paid on account of personal physical injuries or physical sickness be excludable from Claimant's gross income under 26 U.S.C. § 104(a)(2). No Party provides tax advice; Claimant is responsible for Claimant's tax positions.

7.5 Force Majeure. No Party is liable for delays caused by events beyond reasonable control, provided prompt notice and resumed performance.

8. DISPUTE RESOLUTION

8.1 Governing Law. Wisconsin law governs without regard to conflicts principles.

8.2 Forum. Exclusive venue in the Wisconsin Circuit Court for [COUNTY] County, with each Party submitting to that court's jurisdiction.

8.3 Mediation (Optional Pre-Suit). Disputes under this Agreement may, by mutual written consent, be submitted to non-binding mediation before any litigation.

8.4 Jury Trial Waiver (Optional). Subject to Wisconsin law, the Parties knowingly waive jury trial in any action arising under this Agreement.

9. GENERAL PROVISIONS

9.1 Amendments / Waivers. Only in a writing signed by both Parties.

9.2 Assignment. No assignment without prior written consent, except Provider may assign to its insurer or the Fund for payment.

9.3 Successors & Assigns. Binds and benefits the Parties and their successors and permitted assigns.

9.4 Severability. Invalid provisions are construed narrowly; remaining provisions remain in force.

9.5 Entire Agreement. This Agreement supersedes all prior negotiations and writings on the subject.

9.6 Counterparts; Electronic Signatures. Executable in counterparts; electronic signatures (Wis. Stat. ch. 137) are deemed originals.

9.7 Construction. Headings are for convenience; the contra-proferentem rule is waived.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

[Optional — Fund Joinder]
Wisconsin Injured Patients and Families Compensation Fund
By: _____________________________ Title: _________________ Date: [__/__/____]

Schedules

• Schedule 3.1 — Allocation of Settlement Amount (economic / noneconomic / medical expenses)
• Schedule 3.3 — Fund Approval (if applicable)
• Schedule 4.3 — Liens and Subrogation Disclosure
• Schedule A — Periodic Payment Schedule (if Structured Settlement)
• Schedule B — IRS Form W-9

Sources and References

• Wis. Stat. § 893.55 — Medical malpractice; limitation of actions; limitation of damages
• Wis. Stat. § 893.55(4)(d)1 — $750,000 noneconomic damages cap
• Wis. Stat. ch. 655 — Health Care Liability and Injured Patients and Families Compensation
• Wis. Stat. § 655.27 — Injured Patients and Families Compensation Fund
• Wis. Stat. §§ 655.42–655.58 — Medical Mediation Panels
• Wis. Stat. § 655.26 — Reporting to the Wisconsin Medical Examining Board
• Mayo v. Wisconsin Injured Patients & Families Compensation Fund, 2018 WI 78, 383 Wis. 2d 1, 914 N.W.2d 678 (upholding the cap; overruling Ferdon, 2005 WI 125)
• 42 U.S.C. §§ 11131–11137; 45 C.F.R. Part 60 (NPDB)
• 26 U.S.C. § 104(a)(2) (tax exclusion for personal physical injury damages)
• 42 U.S.C. § 1395y(b)(2) (Medicare Secondary Payer)

This template is informational only; engage Wisconsin counsel before use.