Hello There, Guest! Login Register
Index    |     Search    |     Members    |     Help

Thread Rating:
  • 0 Vote(s) - 0 Average
  • 1
  • 2
  • 3
  • 4
  • 5
The word "surgery" has emerged, now IC is disputing liability. Must read!
#1
Rolleyes 
Texas claim- Semi to semi collision

I received a DWC PLN-11 form from Work comp insurance company today and the content is hard to wrap my mind around, I will explain why.

On June 20th I broke my foot due to the treatment of my back.

On August 7, 2017, I received a DWC PLN-11 form from the IC that notified me that the left foot fracture was being disputed and the IC limits my compensable injuries to right lumbar radiculopathy, ruptured lumbar disc, and lumbar disc disease. My adjuster said they would accept it if the designated doctor agrees. (Note that these injuries were being accepted by the IC before I even requested the extent of injury exam.)

On September 22, 2017, I attended the DD examination and the doctor agreed that the injury to my left foot was a direct result of the treatment of my back. He also agreed with the other injuries that I listed on the form as well, they are as follows:

1. Other invertebral displacement lumbar region; M51.26
2. Sprain of ligaments of lumbar spine initial encounter; S33.5XXA
2.Pain in thoracic spine; M54.6
4.Radiculopathy in lumbar region; M54.16
5.Broken left foot; S92.302A
6.Pain in lumbar region; M54.5

On October 9, I spoke with the adjuster and she told me that based of the DD report, they will be accepting liability for my foot.

On October 23, I visited my treating orthopedic surgeon. After 2 failed ESI injection and exhausting physical therapy limits with 24 sessions, he recommended that I have a lumbar fusion done.

On October 24, a peer review is done for an extent of injury upon request by the IC, and the doctor says that my compensability should only be limited to a strain of the thoracolumbar spine, which has been resolved, so no more medical treatment is necessary for that injury. He also mentions that the left foot is not causally related.

Now today, I received an additional DWC PLN-11 form and it states that the IC is limiting compensable injury to a strain of lumbar spine and fracture of left foot only based off of the peer review done on October 24. Even though this same reviewing Doctor said the left foot was not causally related as well.

You read that right! The insurance company is denying everything that the designated doctor listed as compensable injuries, except for the foot injury that happened 4 months after my initial injury date, but they are saying that the back injury that was responsible for the foot injury was resolved at week 6.

Here are my questions.

Are the DWC PLN-11 forms considered to be acceptance of liability forms legally?

If so, can the insurance company continue to change their mind whenever they want to or are they bound to liability by these forms?

How are they able to deny any of the injuries listed as compensable by the Designated Doctor without the preponderance of contrary evidence?
 
Reply
#2
the PLN-11 is a simple notification and is not a binding agreement between the parties or a judicial decision.
comp decisions have to be supported by evidence. as the evidence changes so to should the decisions. the employer/carrier can reverse a denial or an acceptance with a change in evidence.
whether there is a "preponderance" in support of one conclusion or another is up to the commission/ court to determine.
the carrier/employer has no judicial authority decide such matters or decide where "preponderance" lies; Its a judgement call left to the legal system.
the carrier is required to make an administrative decision as they see the evidence.
as the PLN-11 states disputes that can't be resolved between the parties can be taken to a Benefit Review Conference..
there are additional appeals available throughout the legal process.
Reminder
........Each state has their own comp system. We need to know your state to provide accurate information.........
 
Reply
#3
(11-14-2017, 06:25 PM)1171 Wrote: the PLN-11 is a simple notification and is not a binding agreement between the parties or a judicial decision.
comp decisions have to be supported by evidence. as the evidence changes so to should the decisions. the employer/carrier can reverse a denial or an acceptance with a change in evidence.
whether there is a "preponderance" in support of one conclusion or another is up to the commission/ court to determine.
the carrier/employer has no judicial authority decide such matters or decide where "preponderance" lies; Its a judgement call left to the legal system.
the carrier is required to make an administrative decision as they see the evidence.
as the PLN-11 states disputes that can't be resolved between the parties can be taken to a Benefit Review Conference..
there are additional appeals available throughout the legal process.

Great, thank you.

In Texas, is it legal for the IC to ignore the injuries listed as compensable by the Designated Doctor?

Why would they accept the foot injury, but deny the injury that causes the foot injury? Are these common insurance tactics?
 
Reply
#4
I only have your understanding of what has happened and no access to any of the evidence so I can't offer an explanation.
I suggest you contact them directly and get their understanding of the issues and their reasoning.
Maybe they'll agree to reject the foot as well once you point out the inconsistency.
It is common for a carrier to deny an injury or condition when they have a medical opinion that supports such an interpretation.
The employer would likely cancel their policy if a carrier ignored evidence that would reduce the employers costs/liability.
You are not thinking realistically or pragmatically. Your insurance company would not be in business very long if you ignored your customers.
The employer is the customer. If you want to change the carrier's decision, Contact your employer and have them put pressure on the carrier to accept all your conditions and provide all the benefits you want/need.

You do seem to misunderstand the business world and I,m trying to give a glimpse of why the process works the way it does before you get too frustrated or angry.
It's not your claim; it's the employers claim.
Being realistic from the beginning may save you grief in the long run.

Be well.
Reminder
........Each state has their own comp system. We need to know your state to provide accurate information.........
 
Reply
#5
Well, I like your straightforwardness. Thank you for your advice.
I think I will take a stab at contacting the company and see if they can change anything.
 
Reply
#6
Basic misunderstandings of what motivates the participants in the process has lead to much frustration, anger, and hardship in the world of workers comp.
there are a vast number of players -- from politicians, to doctors, to unions, lawyers, carriers, big pharma, etc.
They all have had a hand in shaping what it can and cannot do.
Understanding it's lmits will make it easier to get thru it.
It's BIG$$$ and its complex.
A difficult combination to control.
Let me know what your employer says. Should be an interesting conversation.

PS.
In Texas many employers opt out of workers comp altogether. Those workers are left in very difficult situation.
Reminder
........Each state has their own comp system. We need to know your state to provide accurate information.........
 
Reply
#7
Will do, the company is Pepsi's biggest competitor (Red guys) and they are pretty reasonable. I will let you know what happens.
 
Reply
#8
Guess that conversation did not as well as you thought.
Thanks for posting.
Reminder
........Each state has their own comp system. We need to know your state to provide accurate information.........
 
Reply
  


Possibly Related Threads...
Thread Author Replies Views Last Post
  claims admin calls to tell me they accepted liability now what happens? rxburn 2 1,477 07-31-2014, 02:24 PM
Last Post: rxburn
  shall not redeem liability for the payment QUESTION??? BADHABIT12 1 1,562 04-28-2014, 08:46 PM
Last Post: 1171
  Do I accept my companys first offer on the Final Admission of Liability kranman 1 3,711 09-07-2011, 12:35 AM
Last Post: 1171
  New find of CRPS after Final Admission of Liability lefty 8 11,255 11-16-2010, 06:20 PM
Last Post: lefty
  Filing a notice contesting liability liljerry 6 5,885 11-03-2010, 12:08 PM
Last Post: nursedina
Sad Final Admission Of Liability...Seeing RED! lefty 5 8,543 07-23-2010, 04:36 PM
Last Post: Bad Boy Bad Boy
  IME not immune from civil liability for falsifying medical report 1171 2 7,242 06-19-2010, 01:08 AM
Last Post: chrischris
  Just a word about FMLA kate 8 5,026 06-08-2009, 06:33 PM
Last Post: BooBoosNeck
  Disputing impairment rating, Texas. froglett 2 6,692 06-28-2008, 01:21 PM
Last Post: 1171
  Employer's Percent of Liability katicabogar 8 4,756 02-12-2008, 01:31 PM
Last Post: 1171

Forum Jump:


Browsing: 1 Guest(s)