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Benefits stopped - Printable Version

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Benefits stopped - Big T - 05-29-2011

I am in California and have an Umbilical Hernia. I got this injury lifting a auto transmission at work. After the doc gave me lifting restrictions my employer made me stop working because they couldn't accommodate me in the line of work I do. I started receiving TTD payments shortly after and started seeing the employers doctor. After the 30th day of injury I saw the first surgeon. He stated that because of my weight he would have to admit me into a hospital and do the surgery. He stated I would be there for at least three days in recovery. He stated that he would contact me the following week an have me in to discuss the operation. One whole wee had passed and when I called his receptionist she said my surgery was scheduled for that Friday about 100 miles away from home due to the doctor having privileges at that hospital. I didn't feel comfortable with this doctors ability to treat me so I contacted my insurance adviser and asked for a second opinion.

I went to a second surgeon and he told me he would not perform surgery on me because of my weight and that my condition was a-symptomatic to my condition and I could return to work however he would not release me. Needless to say I called the insurance adjuster and requested a third opinion. I saw the third surgeon and he stated he could do my surgery and it could be done at low risk because he would give me twilight anesthesia. and he could do the operation in an outpatient clinic and I would be back at home the same day. I felt comfortable with his prognosis so we scheduled surgery and it was completed April 11, 2011 I had a follow-up on April 14, 2011 and he said he wanted me to come back May 12, 2011 for another check up.

Approximately a week after surgery I got a benefit check that was 750 dollars less than what I had been receiving for the last 4 months. I called the insurance adjuster and she told me that when she made the calculations for my pay she made a mistake on the date and came up with the wrong amount for my benefit payment. she said the true amount was the new one on my current check. She then said that I would be responsible for the overpayment and I owed the insurance company just under 6000 dollars. She said that I could make payments in any amount I wanted and they would not take me to a collections agency because of her mistake. Not knowing what to do I got out the laptop and found a lawyer. I received a letter from the lawyer and it told me that he was sending me to a new PCP and I should discontinue seeing my prior PCP which was the surgeon that did my hernia operation. I called the surgeons office and cancelled my appointment on May 11, 2011( I was scheduled to go back to him on the 12th). I then went to the PCP assigned to me by the lawyer. I did all the paperwork on the first appointment and went to the second appointment on May 26, 2011. That doctor said since I had surgery already I needed to go to a hernia surgeon as my PCP to get evaluated for work.

When I returned home I found a nice letter in my mail box from the insurance company that said my benefits as of May 9, 2011 were stopped because the insurance company agreed with the operating surgeon that I was fit to return to work. I called my lawyer and explained it all and they are working on getting me a hernia specialist as my PCP and looking into the stuff the insurance company is doing to stop my benefit payments.

Four questions I have are
1 Can the doctor release me without seeing me in his office?
2 How can they stop my benefit payments before I was scheduled to even see the doctor for my follow up?
3 Am I responsible for the insurance companies mistake and subsequent overpayment?
4 Did I do right by trusting my attorney and stop seeing my primary PCP and going to his new PCP?

Thanks for looking Smile



RE: Benefits stopped - 1171 - 05-30-2011

I didn't read the whole post.

yes a doctor can give their opinion without a physical exam.

denial of benefits can be based on other information. they should provide you and your atty with the basis of their denial.

yes money received in error is owed. "finders keepers" does not apply.

judgement on behavior should be based on the consequences which are often not immediately apparent.