Workers' Compensation Discussion Forums
claim accepted surgery denied what happens once i get mmi - Printable Version

+- Workers' Compensation Discussion Forums (https://www.workerscompensation.com/forums/general)
+-- Forum: Category (https://www.workerscompensation.com/forums/general/forumdisplay.php?fid=3)
+--- Forum: Injured Worker Forum (https://www.workerscompensation.com/forums/general/forumdisplay.php?fid=4)
+--- Thread: claim accepted surgery denied what happens once i get mmi (/showthread.php?tid=16501)



claim accepted surgery denied what happens once i get mmi - queenlee - 01-19-2017

I am in Illinois - I got hurt more than 8 months ago at work and had to have a total knee replacement. I was getting ttd and wcomp paid for my initial doctors visits and mri.. after I had an ime it took them weeks to send the report ,,really my attorney had to call  and get a copy...
three weeks later they tried to send me to another ime without addressing my need for surgery,,, the first ime was in my favor,, when I did not get a reason for the second ime... or any return calls to my atty he advised I didn't go,,, this is just some back ground,,, I didn't go...they wrongly stopped my ttd for 8 weeks,,, had a 19b which wc insurance did not attend,,long story short,,
we got the adjusters supervisor on the phone who was clueless about what as going on,, ttd was finally reinstated ..this was over the summer,, well I finally got a denial letter from wc for the surgery so I was able to get it done, I am recovering,,my question is whats next,,will we fight to get them to pay my medical bills,,, will I get my copays back,, will my doc give me a rating,, I hope to be returning to work in the next few months...


RE: claim accepted surgery denied what happens once i get mmi - 1171 - 01-19-2017

Generally litigation moves Down 2 paths at once:
1) You obtain evidence in support of your claims and benefit demands
2) you prepare settlement range- worst case/ best case
You push both forward until you get a hearing or an acceptable deal.
I assume your health insurer has filed a lien for their costs. They'll either get repaid or not depending on the evidence
You can add you co-pays and other out of pocket medical expenses to your settlement range.
Don,t know anything about your doc or if they are qualified to Do a work comp rating.
Multiple factors determine impairment benefits especially cases with similar injuries.


RE: claim accepted surgery denied what happens once i get mmi - queenlee - 01-19-2017

(01-19-2017, 07:56 PM)1171 Wrote: Generally litigation moves Down 2 paths at once:
1) You obtain evidence  in support of your claims and benefit demands
2) you prepare settlement range- worst case/ best case
You push both forward until you get a hearing or an acceptable deal.
I assume your health insurer has filed a lien for their costs. They'll either get repaid or not depending on the evidence
You can add you co-pays and other out of pocket medical Spenser's to your settlement range.
Don,t know anything about your doc or if they are qualified to Do a work comp rating.

thank you for your response,,, okay.. question.. I am on a leave of absence.my doctor will have to sign my return to work papers...will he just sign them or will I need to have an exam/letter from pt. I am still going to pt twice a week..once I get my return date do I simply tell my atty and he notifies WC? thanks in advance


RE: claim accepted surgery denied what happens once i get mmi - 1171 - 01-19-2017

I'm not sure what your LoA papers require him to approve/ agree to.
Your employer has a right to require a fitness for duty exam before putting you back on their job. Whether your LoA forms suffice for that is up to your employer.
Sure or your employer can notify the carrier.


RE: claim accepted surgery denied what happens once i get mmi - queenlee - 01-20-2017

(01-19-2017, 08:11 PM)1171 Wrote: I'm not sure what your LoA papers require him to approve/ agree to.
Your employer has a right to require a fitness for duty exam before putting you back on their job. Whether  your LoA forms suffice for that is up to your employer.
Sure or your employer can notify the carrier.

Ok.. My employer requires a return to work form that goes to the the third party administrator and says my return date and any restrictions.. so when I go in next month to the doctor..he will review the PT report and we will discuss my return to work... im not sure if I have to do any type of fitness test.. I guess I will find out soon enough,,

same folks that handle our LOA also handles our workers comp.. so confusing at times