Injured in September of 2006, off of work since then, with three different surgeries to repair broken tibia/fibula, along with ACL and meniscus repair. Now September 4th, I experience a total knee replacement, due to the arthritis caused by my injury, at the young age of 52.
Doc says they last from 10-15 years, so that puts me in my mid 60’s needing another, he also said you can only have two!
My question, can I expect WC to pay for the next surgery in 10-15 years, or do you think they will try to “buy†me out?
Is there expiration on WC covering medical?
And God’s will I live long enough to wear out the 2nd knee, is that considered in determining my impairment rating?
Thanks for the help!
you should NOT expect comp to pay for a surgery 10 or 15 years in the future. The chance that the need for surgery can be directly linked to an event in sept 2006 and not any intervening conditions or activity maybe difficult at best and contested at least.
workers comp is not health insurance. you are not covered. parts of your body are not covered.
The employer is covered.
only the injury that hapened on the job is covered.
all other activities, conditions, events, causes, etc. are not covered.
this confusion and misunderstanding often leads to frustration with the system.
Pote;
Based on what I have read at this site alone, it seems that future medical is an uphill battle to get WC to cover. Might WC try and buy out the medical? Perhaps. But if your Dr is saying the knee will only last x amount of time until it needs to be replaced again then future medical is something you might want to hold steadfast on. That or make sure it is considered in your settlement so you will have the funds to afford it down the road.
What I don't understand is why 1171 feels that WC shouldn't be responsible for a 2nd surgery when the physicians say, upfront, that the first surgery is only a temporary fix. I can understand if a surgery is the permenant fix that anything else down the road perhaps shouldn't be covered, but when the Dr says the knew knee will only last 10-15 years then the fix is only temp and the very least you or anyone else is owed from the companies insurance is to be made whole, or as close to whole as possible. It's not like pote is asking for liposuction because of weight gain for not being able to walk due to surgery.
dsny1mom
I was injured 11/05 and have had minescus surgery on both knees.
I have been waiting 22 months for approval for a total knee replacement.
My attorney has told me after I have this surgery and previous to settlement he will petition to keep my medical open due to the need of futher surgeries to the knee requiring the knee replacement.
I think most WC insurance policies only cover 1 prosthetic. Most people when they think of prosthetics think of arms, legs, etc - but knees, hips, shoulders are also considered prosthetics by the medical community.
first off you would have to prove that you didn't have arthritis prior to the injury and that the injury was a direct cause of you needing the knee replacement at this time. If your doctor is backing you up and you have open medical and didn't take a lump sum settlement then you can have him submit a request for the surgery to the insurance company. They in turn will send you to an IME and get a different opinion.
Your next step will be to take this all to court and let the judge decide on the matter. So all the documentation showing that it developed after the injury and was a direct cause of the injury should be in your files, hopefully. The more medical on your side the better. Remember to get copies of all your medical reports - both hand written along with the typed up ones.
As for the prosthetics 1171 or dallas can correct me on that - but I do believe not only does it fall under the insurance policies but also under most state laws about the IC being liable for just the 1 replacement. You can check out your state laws on artificial limbs/prosthetics - and most may classify a knee replacement under the artificial limb/prosthetics category. Just rememeber not all prosthetics are external.
1171, I think I understand what you saying, however, if “Doc†says that the knee replacement surgery is needed due to the injury (IC Ok’d the Sept 4th surgery), than why wouldn’t they be responsible for additional surgeries pertaining to the same injury, when it has been documented that the “new kneeâ€Â, has a short life-span?
I had a company physical/stress test on my knees just 6 weeks prior to injury, and I was placed in the upper percentile for strength, I believe this should help my case as far as “knee replacement†being part of the injury
1171, I am learning to respect your knowledge and your candid responses.
The answer is that it depends. Each state' laws are different and each set of facts is different. In PA, medical coverage is potentially permanent in regard to treatment for the work injury. Since 1996, settlement of medical through a lump sum has been allowed and often happens. If the first knee replacement was related to the work injury, and your doctor properly documents his file that a second knee replacement will be necessary in the future as a result of the work injury, I think you have a good shot of having this surgery covered. (This assumes the laws in your state are the same as PA which may not be the case.) Will the insurance company deny payment and make you fight to get it? Probably, but they are not in the business of paying out money, they are in the business of taking in money, so this is nothing new.
pote2002 Wrote:1171, I think I understand what you saying, however, if “Doc†says that the knee replacement surgery is needed due to the injury (IC Ok’d the Sept 4th surgery), than why wouldn’t they be responsible for additional surgeries pertaining to the same injury, when it has been documented that the “new kneeâ€Â, has a short life-span?
I had a company physical/stress test on my knees just 6 weeks prior to injury, and I was placed in the upper percentile for strength, I believe this should help my case as far as “knee replacement†being part of the injury
1171, I am learning to respect your knowledge and your candid responses.
Hi Pote, I Hope you are well Today! So as not to make this too complicated I see three scenarios:
1- If Your State leaves Medical Open for Life on w/c claims, you injury is covered, along with any complications that may arise in the Future, Provided the i/c doesn't, as they usually do find a way to stop your Open Medical as often happens with a Lifetime Open Medical.
2- If you settle by means of a C&R (Compromise and Release) you close your Medical for x amount of Dollars, and the future Medical is to be Paid by you.
3- If you are Disabled by your injury, and you settle using a Medicare Set-Aside, your injury would be covered for Life, either w/c or Medicare at that time would Pay.
Number 3 is the only absolute way that you can guarantee that Future Medical will be Paid. Throughout the Course of you being on Lifetime Medical left open by w/c, they are going to try and make you MMI., or try and find some way to end your Benefits. I've seen Benefits stopped for something as simple as missing a Dr.'s appt., or not scheduling one in a certain time period. Open Medical sounds good on the face of things, but rarely does anyone get the full care they need. So in theory Yes, you should be covered, in Reality, Probably Not!
dsnymom:
sorry if you misunderstood pote2002's question:
"My question, can I expect WC to pay for the next surgery in 10-15 years..."
It was not asked what
should happen or what other posters would like to happen.
My opinion is that pote2002 should not expect them to pay for the surgery 10-15 yrs out or least expect that the carrier will deny the surgery and contest liability for it.
no one, of course, can predict the future so any answer will be a guess
it might be interesting to start another thread along the lines of your question as to what changes workers would like to see made to work comp laws and which ones would be likely to happen
Still in Limbo Wrote:Hi Pote, I Hope you are well Today! So as not to make this too complicated I see three scenarios:
1- If Your State leaves Medical Open for Life on w/c claims, you injury is covered, along with any complications that may arise in the Future, Provided the i/c doesn't, as they usually do find a way to stop your Open Medical as often happens with a Lifetime Open Medical.
2- If you settle by means of a C&R (Compromise and Release) you close your Medical for x amount of Dollars, and the future Medical is to be Paid by you.
3- If you are Disabled by your injury, and you settle using a Medicare Set-Aside, your injury would be covered for Life, either w/c or Medicare at that time would Pay.
Number 3 is the only absolute way that you can guarantee that Future Medical will be Paid. Throughout the Course of you being on Lifetime Medical left open by w/c, they are going to try and make you MMI., or try and find some way to end your Benefits. I've seen Benefits stopped for something as simple as missing a Dr.'s appt., or not scheduling one in a certain time period. Open Medical sounds good on the face of things, but rarely does anyone get the full care they need. So in theory Yes, you should be covered, in Reality, Probably Not!
Pote,
The Penquin of Justice quite precisely summed it all up for you.