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Looking for input - CA work comp *relapse - Printable Version

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Looking for input - CA work comp *relapse - BB019 - 05-26-2015

Hi - I really need some guidance, feedback, just a different perspective because I am going a little nuts here trying to figure out how best to help myself. I have an ongoing open work comp claim for medical only. I recently had to go back out on leave due to relapse. I had my QME recheck and am pending results, but my company's ins carrier for short term disability denied my claim. I have to appeal it. I have a work comp atty. I consulted another atty (employment law? I think?) and if I understand right, now need to find an ERISA familiar atty. No one I've talked to seems to be able to assist me with filing the appeal, so here I sit, scared to do it wrong and not getting paid.


RE: Looking for input - CA work comp *relapse - BB019 - 05-26-2015

Forgot to mention, that while I was on this leave, I also had surgery that is not workers comp related and I tried for 6 weeks to get information on how to do the dual claims but was just told to remind them at the time so they changed it and then when to change it back but to use one claim #. So now, I'm denied for that too, by default. My work is sending me notices that are false, and upon reviewing my file again and comparing dates, I believe they are the reason the insurance company denied me. I didn't realize that until tonight.


RE: Looking for input - CA work comp *relapse - 1171 - 05-26-2015

I assume the information you are referring to is non-medical.
there is no set standard on what personal information you should reveal and what you withhold.
any information withheld that is likely to alter or affect the physician's determination of liability can result in the opinion being thrown out.
a physician's opinion is evidence and if it is incomplete in a manner that is material to the conclusion it can be challenged before the judge.
basically the comp court decides what was relevant to disclose after the fact.
your atty should advise you on specific details may be relevant to your claim.



RE: Looking for input - CA work comp *relapse - BB019 - 05-26-2015

I apologize, I believe my inquiry is not one that would involve a court, this is just for my company's disability benefits. And I have a doctor's note placing me on leave (for both my Stress claim that is pending, and the carpal tunnel surgery). So the appeal I am filing, is directly with the ins company, and will be reviewed internally by the ins company's appeal review committee - but this isn't involving a court or a doctor who would determine my overall status - my doctor already has me out on approved medical leave. The doctors note is all my work needs, and the last time I was out for so long, I was never denied because I always had a doctors note, now they are denying me because of lack of details demonstrating I cannot perform my work duties. Again, the confusion is on me and I apologize. Thanks for your input and I look forward to more comments. I agree my atty should help me, why he isn't is something I'm waiting for his answer on. I emailed him this morning as I don't know if he received my phone message or if the office just took it upon themselves to answer for him. I guess I want to give him that benefit of the doubt. Thanks.


RE: Looking for input - CA work comp *relapse - 1171 - 05-26-2015

since the issue is not determined by work comp laws, you probably need help from an employment law atty or civil contract lawyer.
I suspect that like workers comp, the disability insurer will only provide benefits based on a doctor's opinion that your current lost time is due to a medical condition and is medically necessary.



RE: Looking for input - CA work comp *relapse - BB019 - 05-26-2015

(05-26-2015, 04:34 PM)1171 Wrote: since the issue is not determined by work comp laws, you probably need help from an employment law atty or civil contract lawyer.
I suspect that like workers comp, the disability insurer will only provide benefits based on a doctor's opinion that your current lost time is due to a medical condition and is medically necessary.

"the disability insurer will only provide benefits based on a doctor's opinion that your current lost time is due to a medical condition and is medically necessary." Right - I actually have this, but the insurance company says that isn't enough. I thought this step was only a formality, so I didn't think with the doctors note I would be denied. Let me know if I'm not following what you are saying though - I do really need to understand this better. Thanks!


RE: Looking for input - CA work comp *relapse - BB019 - 05-26-2015

I forgot to mention, I have a referral to an employment lawyer, and left him a message this afternoon. Thank you for the suggestion!


RE: Looking for input - CA work comp *relapse - 1171 - 05-27-2015

you will need a copy of the disability insurance policy and it should state what is needed to qualify for benefits and what qualifies as "disability".
under california law a dispute about the entitlement to benefits is not left solely to the carrier but is reviewable by the civil courts.
The california department of insurance regulates accident and disability insurance within the state and such policies are subject to the standards of fair settlement practices.
any violation can be the subject of a complaint to the insurance commissioners office:
http://www.insurance.ca.gov/01-consumers/130-laws-regs-hearings/05-CCR/fair-claims-regs.cfm



RE: Looking for input - CA work comp *relapse - BB019 - 05-27-2015

Thank you very much. I have requested a copy of the insurance policy from my case manager for my claim.


RE: Looking for input - CA work comp *relapse - California_Help - 05-28-2015

I am a little confused on your current situation. Is it a STD (short term disability) policy that has denied your claim? If so you need a ERISA attorney. Work comp attorney's know very little about STD/LTD policies, and thier job is only to represent you in your work comp claim.


You may be able to qualify for state disability. Have you applied?

Why are you not receiving TTD if you have been taken off of work from a doctor for a work related injury?