disabled plumber in NJ need 2 shoulder replacement

[gsx99]

been collecting ssd fo 2years been out of work since 2008 lawyer called and said that the insurance company is coming back in 6 weeks with a dollar amount can anyone give me any idea what to excpectas far as dollor wise and do i recieve any money from back years 2008 to present. I had surgury done to my left shoulder but that faILEDNOW IM TOLD i NEED 2 SHOULDER REPLACMENT I HAVE BEEN SEEING PAIN MANAGMENT DOCTOR AND THE ORTHOPEDEIC SURGEON ON A MONTHLY BAsis.

thanks for any help

[1171]

your atty knows your case better then anyone.

the amount is not based on what treatment you received or the doctors that are treating you. everyone's disability and medical needs are different so there is no one figure right for everyone.

[bugmann]

Hello GSX99,

First I want to say how sad I am to hear of your serious injury. It sounds terribly painful!! I will "try" to explain to you how NJWC law/rules will effect you with the limited info that you have provided. As you may know your TTD benefits ended when the WC Dr rated you MMI, (this may not apply if you were under a work agreement with employer at the time of injury,) as that would supercede the bare bones min WC law benefits) If your lawyer filed for 2nd Injury Fund benefits and if successful these benefits would continue from the dates of your last TTD benefit paid by the carrier through the duration of total disability. The 2nd Injury Fund or (2nd IF) is the State of NJ not the carrier.

As for your settlement, I dont know ANY lawyer who would answer your question of what $$ can you expect. As the seated JUDGE of Compensation will have the final say so on this issue.

A case is not over until a determination is made, either via negotiation or trial, as to how disabled the worker is. The outcome of this determination reflects the worker's permanent disability: an impairment that restricts a body function, and which is verifiable by objective medical evidence. Any lessening in the worker's ability to perform his job must be considered as a significant factor in determining permanent disability. To position itself for trial, or pretrial (a proceeding in court where the parties negotiate settlements), the worker's attorney will send him to examining doctors who prepare evaluation reports. Before setting up examinations, however, the attorney must make sure that no further treatment is necessary, and that all records of the workers' medical treatment are sent to the examining physician for review. Otherwise, the examining physician may reach a conclusion without considering relevant evidence. A faulty conclusion may underestimate a worker's permanent disability or render less credible a favorable estimate. These examining Drs are considered experts by the WC courts.
If the worker's skills are limited, and his job imposes significant physical demands, the worker's attorney should advise the examining physician to evaluate the worker in light of these circumstances. A computer programmer with a severe leg injury will be less disabled than a floor tile installer with the same injury who possesses a limited education. The floor tile installer has to use his legs more to perform his job than a programmer who sits in a chair for most of the day. And if the tile installer's injury prevents him from performing manual labor in the future, he will find it much more difficult to get an office job than the computer programmer or some other college-educated worker. Of course, if the programmer injures a hand or wrist, or is afflicted by carpal tunnel syndrome, her ability to earn a living may be affected in a way comparable to a floor tile installer with an identical injury. Unless instructed otherwise, Petitioners' examining doctors often fail to note factors such as the nature of the Petitioner's job, and the Petitioner's level of skill, which is relevant to ability to earn a living in other fields if a Petitioner is totally disabled in a given occupation. In addition, where the worker has limited skill and job options, his attorney must stress these factors to the insurance company and the judge as well.

The insurance carrier will also send the worker to an examining doctor or doctors. These doctors conduct examinations and set forth numbers representing estimates of the worker's disability. Doctors used by the employer will always give an estimate lower than the estimate provided by the worker's doctors. For instance, in the case of an unoperated herniated disc with minor nerve impingement, the worker's orthopedic expert may fix the worker's disability at 45% of partial/total disability. *(1)*The employer's orthopedic specialist may find a partial/total disability of 5%. Ultimately the case will, in all probability, be resolved at a figure in between these two estimates.

The numbers used by examining doctors refer to charts published yearly by the New Jersey Division of Workers' Compensation. These charts assign dollar values to percentages of disability ranging form 1% to 100%. In the example just used, if the accident occurred in the year 2000,*(2)*5% of partial/total disability translates in dollars to $4,530.00, and 45% of partial/total disability translates to $92,000.*(3)* Different rates apply to different categories of injuries. A back injury is classified as "partial/total." This classification mandates a greater figure in dollars for any given percentage of disability than, for example, an injury to an arm or a leg. Whereas an award of 20% of partial/total is worth $19,536.00, an award of 20% partial disability for a leg is worth $9,513.00; 20% for a hand is worth $7,399.00; and for an ear, $1,812.00.

Medical examinations to determine permanent disability may not be undertaken until 6 months (26 weeks) after the employee's authorized medical treatment ends, or 6 months from the date the employee returns to work, whichever is earlier. This delay is built into the system to insure that the employee's condition remains permanent and stationary before any final determinations as to permanent disability are made. After all examinations are finished, the parties meet in court for a pretrial—a discussion and negotiation session between the attorneys, held in the judge's chambers. The worker's attorney should know if the defense is ready to discuss settlement, in which case the worker will be asked to appear in court to approve or reject settlement offers. If an agreement is reached, the worker will take the witness stand to indicate he understands and approves of the settlement. If the parties cannot settle the case, it will be set for trial.

In your situation a shoulder (one) would net a partial disability classification, however (two) shoulders could arguably change the classification in my opinion. In any event once you have reached MMI status your injury care is considered palliative care and no longer corrective care thus not covered by NJWC law. (Again it may be covered if your work agreement states so) Its very possible the ins carrier will not approve the double shoulder replacement and give you MMI rating as you are?? If they do authorize the double shoulder replacement you will be back under corrective medical care thus entitles you to TTD benefits, and medical care. Then once you have completed therapy and get MMI rating again the above process begins. From the tone of your post to me it appears that the ins carrier has deemed you MMI, and are coming back with their offer, but for thei they would have had to sent you to their medical expert for a rating of impairment. You can the listing of ratings for "partial disability" ratings for the year of 2008 which I bel;eive you claim the injury was sustained @ http://lwd.dol.state.nj.us/labor/forms_p...hedule.pdf

under arm section, however as I stated the duel shoulder can be argued as partial/total disability and this figure will need to be litigated once a rating of impairment is established. Do you have any numbers yet either from your side or the ins carriers drs?? As this will be your settlement, and if you are not eligible for 2nd IF this will be a LARGE pill for your employer to swallow? However I feel that the 2nd IF would benefit you the most.

As you may now see MUCH more information is required to have a discussion on what may be expected?

I rarely post here as its difficult to find cases that deal with NJWC law specifically, as this is the state that I have my primary focus on. No I am not an attorney but I have been introduced personally to the NJWC total disability system and have done extensive research, and studies on it. So I understand many of your frustrations, GOOD LUCK, and post any questions u may still have?

BUG

*(1)* "Partial/total" is a classification of disability applied to injuries or occupational diseases that do not fit into the other enumerated categories: hand, arm, thumb, fingers, leg, foot, toes, eyes, and ears. Injuries to the neck, back, and head, among many others, fall into the partial/total category.

*(2)* Figures for previous years are lower.

*(3)* These figures assume that the worker is earning a certain minimum weekly wage, which if not reached would lower the amount of recovery

(12-14-2011 06:29 PM)gsx99 Wrote:  been collecting ssd fo 2years been out of work since 2008 lawyer called and said that the insurance company is coming back in 6 weeks with a dollar amount can anyone give me any idea what to excpectas far as dollor wise and do i recieve any money from back years 2008 to present. I had surgury done to my left shoulder but that faILEDNOW IM TOLD i NEED 2 SHOULDER REPLACMENT I HAVE BEEN SEEING PAIN MANAGMENT DOCTOR AND THE ORTHOPEDEIC SURGEON ON A MONTHLY BAsis.

thanks for any help

[jayne]

gsx99 welcome and while some rules are by state your help is always welcome on generic WC questions..

[gsx99]

(12-18-2011 06:52 AM)bugmann Wrote:  Hello GSX99,

First I want to say how sad I am to hear of your serious injury. It sounds terribly painful!! I will "try" to explain to you how NJWC law/rules will effect you with the limited info that you have provided. As you may know your TTD benefits ended when the WC Dr rated you MMI, (this may not apply if you were under a work agreement with employer at the time of injury,) as that would supercede the bare bones min WC law benefits) If your lawyer filed for 2nd Injury Fund benefits and if successful these benefits would continue from the dates of your last TTD benefit paid by the carrier through the duration of total disability. The 2nd Injury Fund or (2nd IF) is the State of NJ not the carrier.

As for your settlement, I dont know ANY lawyer who would answer your question of what $$ can you expect. As the seated JUDGE of Compensation will have the final say so on this issue.

A case is not over until a determination is made, either via negotiation or trial, as to how disabled the worker is. The outcome of this determination reflects the worker's permanent disability: an impairment that restricts a body function, and which is verifiable by objective medical evidence. Any lessening in the worker's ability to perform his job must be considered as a significant factor in determining permanent disability. To position itself for trial, or pretrial (a proceeding in court where the parties negotiate settlements), the worker's attorney will send him to examining doctors who prepare evaluation reports. Before setting up examinations, however, the attorney must make sure that no further treatment is necessary, and that all records of the workers' medical treatment are sent to the examining physician for review. Otherwise, the examining physician may reach a conclusion without considering relevant evidence. A faulty conclusion may underestimate a worker's permanent disability or render less credible a favorable estimate. These examining Drs are considered experts by the WC courts.
If the worker's skills are limited, and his job imposes significant physical demands, the worker's attorney should advise the examining physician to evaluate the worker in light of these circumstances. A computer programmer with a severe leg injury will be less disabled than a floor tile installer with the same injury who possesses a limited education. The floor tile installer has to use his legs more to perform his job than a programmer who sits in a chair for most of the day. And if the tile installer's injury prevents him from performing manual labor in the future, he will find it much more difficult to get an office job than the computer programmer or some other college-educated worker. Of course, if the programmer injures a hand or wrist, or is afflicted by carpal tunnel syndrome, her ability to earn a living may be affected in a way comparable to a floor tile installer with an identical injury. Unless instructed otherwise, Petitioners' examining doctors often fail to note factors such as the nature of the Petitioner's job, and the Petitioner's level of skill, which is relevant to ability to earn a living in other fields if a Petitioner is totally disabled in a given occupation. In addition, where the worker has limited skill and job options, his attorney must stress these factors to the insurance company and the judge as well.

The insurance carrier will also send the worker to an examining doctor or doctors. These doctors conduct examinations and set forth numbers representing estimates of the worker's disability. Doctors used by the employer will always give an estimate lower than the estimate provided by the worker's doctors. For instance, in the case of an unoperated herniated disc with minor nerve impingement, the worker's orthopedic expert may fix the worker's disability at 45% of partial/total disability. *(1)*The employer's orthopedic specialist may find a partial/total disability of 5%. Ultimately the case will, in all probability, be resolved at a figure in between these two estimates.

The numbers used by examining doctors refer to charts published yearly by the New Jersey Division of Workers' Compensation. These charts assign dollar values to percentages of disability ranging form 1% to 100%. In the example just used, if the accident occurred in the year 2000,*(2)*5% of partial/total disability translates in dollars to $4,530.00, and 45% of partial/total disability translates to $92,000.*(3)* Different rates apply to different categories of injuries. A back injury is classified as "partial/total." This classification mandates a greater figure in dollars for any given percentage of disability than, for example, an injury to an arm or a leg. Whereas an award of 20% of partial/total is worth $19,536.00, an award of 20% partial disability for a leg is worth $9,513.00; 20% for a hand is worth $7,399.00; and for an ear, $1,812.00.

Medical examinations to determine permanent disability may not be undertaken until 6 months (26 weeks) after the employee's authorized medical treatment ends, or 6 months from the date the employee returns to work, whichever is earlier. This delay is built into the system to insure that the employee's condition remains permanent and stationary before any final determinations as to permanent disability are made. After all examinations are finished, the parties meet in court for a pretrial—a discussion and negotiation session between the attorneys, held in the judge's chambers. The worker's attorney should know if the defense is ready to discuss settlement, in which case the worker will be asked to appear in court to approve or reject settlement offers. If an agreement is reached, the worker will take the witness stand to indicate he understands and approves of the settlement. If the parties cannot settle the case, it will be set for trial.

In your situation a shoulder (one) would net a partial disability classification, however (two) shoulders could arguably change the classification in my opinion. In any event once you have reached MMI status your injury care is considered palliative care and no longer corrective care thus not covered by NJWC law. (Again it may be covered if your work agreement states so) Its very possible the ins carrier will not approve the double shoulder replacement and give you MMI rating as you are?? If they do authorize the double shoulder replacement you will be back under corrective medical care thus entitles you to TTD benefits, and medical care. Then once you have completed therapy and get MMI rating again the above process begins. From the tone of your post to me it appears that the ins carrier has deemed you MMI, and are coming back with their offer, but for thei they would have had to sent you to their medical expert for a rating of impairment. You can the listing of ratings for "partial disability" ratings for the year of 2008 which I bel;eive you claim the injury was sustained @ http://lwd.dol.state.nj.us/labor/forms_p...hedule.pdf

under arm section, however as I stated the duel shoulder can be argued as partial/total disability and this figure will need to be litigated once a rating of impairment is established. Do you have any numbers yet either from your side or the ins carriers drs?? As this will be your settlement, and if you are not eligible for 2nd IF this will be a LARGE pill for your employer to swallow? However I feel that the 2nd IF would benefit you the most.

As you may now see MUCH more information is required to have a discussion on what may be expected?

I rarely post here as its difficult to find cases that deal with NJWC law specifically, as this is the state that I have my primary focus on. No I am not an attorney but I have been introduced personally to the NJWC total disability system and have done extensive research, and studies on it. So I understand many of your frustrations, GOOD LUCK, and post any questions u may still have?

BUG

*(1)* "Partial/total" is a classification of disability applied to injuries or occupational diseases that do not fit into the other enumerated categories: hand, arm, thumb, fingers, leg, foot, toes, eyes, and ears. Injuries to the neck, back, and head, among many others, fall into the partial/total category.

*(2)* Figures for previous years are lower.

*(3)* These figures assume that the worker is earning a certain minimum weekly wage, which if not reached would lower the amount of recovery

(12-14-2011 06:29 PM)gsx99 Wrote:  been collecting ssd fo 2years been out of work since 2008 lawyer called and said that the insurance company is coming back in 6 weeks with a dollar amount can anyone give me any idea what to excpectas far as dollor wise and do i recieve any money from back years 2008 to present. I had surgury done to my left shoulder but that faILEDNOW IM TOLD i NEED 2 SHOULDER REPLACMENT I HAVE BEEN SEEING PAIN MANAGMENT DOCTOR AND THE ORTHOPEDEIC SURGEON ON A MONTHLY BAsis.

thanks for any help

bug thank you for you;er response. I have to go back to the begining and tell you what had happened back in 2006 -2008 I was in and out of hospitals due to pains in my arms going around my shoulder blades and to the back of my shoulder blades.( IM ALSO A DIBETIC ) being scared that I was having heart attck symtems I would go to the hospitals after going threw all the tsts they always rulled out heart attacks thank god. One day I was working on my back under sinks for a week straight and the pains came back big time I went to the doc and he sent me for exrays they came back with severe degenritive bone diseise both shoulders where bone on bone with no bursa left at all my shoulders were locking up on me when I would try to pick them up . I went to see an ortho on my on to see if the problems could get fixed and decided to have shoulder surgery on one of my arms to see what the outcome would be keep in mind that all this was done using my sick time. to make the story shortthe surgery failed .so I took and received a partial dissability retirement (wich was equal to %44 of wages) then I hired AN attorny and filed for SS at first I was denied then after going to court I was approved I received a lump sum from SS so now after all this time iv only collected SS and my partial dissability pention.ALso back in 2008 when I filed for SS I also open up my comp case while never receiving anything from work other then pent.IV been to see their ortho i have been to see one that my lawyer sent me to and I also went to one that my employer sent me to when I was fileing for diss. last year my lawyer had said that he was going to file for the SIF.He explained to me that if I was to get this that I would recieve about 1700 a month my questions are due they pay back wages from 2008 when I left with my injury and or is their a settlement for my medical bills both past and the future my orthos told me that I can never due the work that I was dueing because shoulders only last 10 to 12 years so being IM only 50 I might need 2 sets.

[bugmann]

gsx99

Certainly you opting to avoid use of WC in the beginning presents issues, but a lawyer experienced in njwc can get around this. Its my guess your attorney will file for a section 20 settlement which will circumvent many problems that i can foresee and not see.

In NJ WC is 3 fold:

1) Corrective medical care for your injury.
2)TTD while under corrective medical care and unable to do your job or any sedentary work made available by your employer
3) Compensation for the measurable amount of impairment due to your employment.

THE END.

I dont believe you will be receiving any medical care benefits, as that time has past for that. Without playing 20 questions I am guesstimating your lawyer will file for the section 20 settlement and you will be successful in your bid for SIF. This would be a reasonable scenario given the facts that you have shared. I would ask your lawyer if this is his plan? If so you have been well represented in my opinion.

once you have been established as medical max improved your case is ready to move to phase 3 which is comp for your measurable impairment. In cases like yours where there was no TTD or even corrective medical care, if your lawyer can establish that your current condition is at least 1% due to your employment you can file for what's called a section 20 settlement. You can keyword "section 20 settlements and NJ work comp" for details on this. This will only get you comp for the measurable amount of impairment due to your employment. This is given in % of impairment which was the reason for your medical exams. Your partial disability pension & SSDI will need to be calculated into your SIF benefits due to the double dip rule which means you can not receive comp for the same impairment % for the same time periods.

As I wrote earlier the SIF is from the State of nj and not WC. How you become eligible for SIF is you must have had a qualifying pre existing medical condition then have had a work injury that has now left you totally disabled. Getting a determination of total disability from the SSA will definitely help strengthen your position for SIF benefits. Once on the SIF you will get yearly forms that you must fill out and return during your period of disability, also your Dr will get notified similar to how SS will, to see if you are under continued care and if you are unemployable. You will get a full review for SIF at 450 weeks of continued disability then you will just get the yearly forms until your disability ends or death. If you were married at the time of your work injury your wife may be due spouse benefits should you die, so make sure she is aware of this.

Unfortunately you have seen the denial process of the SSA. This is a screening tool used by the SSA determination board, which in NJ is a dept., of the NJ dept. of Labor.

To sum up your questions asked is NO you will not receive back lost wages from 2008. As for medical bills that you paid out of pocket I am unsure but I believe NO. However your insurance may be entitled to reimbursement from your WC carrier I am unsure how that works as most of those I have worked with in the past were not section 20 claimants but went through the entire WC circus act, be thankful you got to miss this part!!!!!!!!! Just remember this, upon acceptance of a Section 20 settlement, the injured worker will waive their right to reopen their case and to seek additional medical treatment or additional benefits. However in a case like yours where "quality" corrective and or palliative care (palliative care is not a NJWC benefit) is required I feel you are better off selecting your own Drs for the care you need. If you reopened your claim through NJWC your employers ins carrier would select all your Drs and care programs and trust me this is not always in the best interest of the injured worker. In considering your on SSDI and awaiting decision on your SIF benefits again I would say your lawyer did you great justice in seeking a section 20 settlement and you getting on with the rest of your life.

The lump sum you received from SSDI was most likely your SSDI benefits due from your application date to your approval date.

I think the 1700 a month due if approved for SIF includes your SSDI monies. As there is an 80% rule which means under the SIF your benefits will not exceed 80% of your past wages (your best years) up to the state max weekly benefit. In 2008 it was $742 a week. I have no idea what a plumber would make, Only you know what your wages were so if you were making around 500-600 a week the 1700 sounds about right. Math is not my proudest subject!! If however you were making 1000-1200 a week for 5 yrs or better in a row the 1700 may be just the SIF as the max benefit would be pert near 3000.00 a month allowed under the SIF benefits max allowance along with your SSDI, give or take a few bucks

I hope this has been somewhat helpful to you. Good luck

BUG





[/quote]bug thank you for you;er response. I have to go back to the begining and tell you what had happened back in 2006 -2008 I was in and out of hospitals due to pains in my arms going around my shoulder blades and to the back of my shoulder blades.( IM ALSO A DIBETIC ) being scared that I was having heart attck symtems I would go to the hospitals after going threw all the tsts they always rulled out heart attacks thank god. One day I was working on my back under sinks for a week straight and the pains came back big time I went to the doc and he sent me for exrays they came back with severe degenritive bone diseise both shoulders where bone on bone with no bursa left at all my shoulders were locking up on me when I would try to pick them up . I went to see an ortho on my on to see if the problems could get fixed and decided to have shoulder surgery on one of my arms to see what the outcome would be keep in mind that all this was done using my sick time. to make the story shortthe surgery failed .so I took and received a partial dissability retirement (wich was equal to %44 of wages) then I hired AN attorny and filed for SS at first I was denied then after going to court I was approved I received a lump sum from SS so now after all this time iv only collected SS and my partial dissability pention.ALso back in 2008 when I filed for SS I also open up my comp case while never receiving anything from work other then pent.IV been to see their ortho i have been to see one that my lawyer sent me to and I also went to one that my employer sent me to when I was fileing for diss. last year my lawyer had said that he was going to file for the SIF.He explained to me that if I was to get this that I would recieve about 1700 a month my questions are due they pay back wages from 2008 when I left with my injury and or is their a settlement for my medical bills both past and the future my orthos told me that I can never due the work that I was dueing because shoulders only last 10 to 12 years so being IM only 50 I might need 2 sets.


[/quote]