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CA: where to begin...UR doctors lying and intentionally delaying treatment
#1
Oh, where to begin as I have so many questions. I could use some help please. I'm furious, depressed, and almost out on the street because of my injury.

I injured my tailbone on 6/13/06 at a work event in CA. However, I worked/live in Colorado. Company is based in CA so my case fell under CA jurisdiction. As well, I get to choose my doctors, NOT the insurance company, because I am not based in CA. AME agreed with coccydynia diagnosis (extreme tailbone pain when sitting) and gave me a 14% permanent disability rating. Had every treatment under the sun; steroid injections (8+) , nerve blocks (6+), physical therapy (2 different times for 6+ months), acupuncture, chiropractic, trigger point injections (3+), massage, etc... NOTHING worked. Finally had my tailbone entirely removed (all 5 segments) a year ago. Followed up with physical therapy. Surgery pain was excruciating and pain got a bit better, but never got me to my zero point before surgery. Had several relapses and would be unable to do much of anything but lie down for 3 - 4 weeks at a time. The pain was just too much. Doctors said they couldn't do anything more for me so they referred me to one of my previous physiatrists for pain management. Became and am EXTREMELY depressed that my life will be like this forever. Been on extended release narcotics/nerve pain meds 24/7 for months + 1 vicodin a day. This doctor thought of one last possibility for me which is a nerve stimulator. You do a 5 day trial and if it doesn't work then that's it. If it does work then a permanent one is placed in my back.

With that said here's my first question (I'll post other ones separately.)

1) Doctor submitted for the nerve stimulator. UniMed Direct did the UR and denied it saying that they left 2 messages for my doctor with his assistant and they never spoke to him. I know this is bullsh*t and I have the phone records to prove that my doctor spoke to them. Only question the UniMed doctor asked my doctor on the phone was if I had physical therapy. My doctor told them that I had several times for several months and that it had not worked. UniMed doctor didn't ask my doctor any other questions.

How can the UniMed doctor be allowed to lie on their report and say that they never spoke to my doctor? Isn't the point of a UR to do a peer review? So why are they asking my doctor for information that is clearly written on my medical records sitting in front of them? This has continued to happen to me with every single UR I have had in the past. I know this is another way for them to intentionally delay, but how can this be legal? I have an attorney, can he do anything about the fact that they are flat out lying and not doing a peer review like they are supposed to? I've already been awarded future medical so why does it continually have to be a push to get anywhere? Lastly, for every other UR I have had UniMed referenced the ACOEM guidelines. Now suddenly in this new UR denial letter they are quoting California MTUS-Updated 2009 Chronic Pain Medical Treatment Guidelines? When did this become the new set of guidelines to follow?

I'm at my lowest point in my life so please any help I can get here is very much appreciated.
nicole
 
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#2
worked/live in Colorado

It has always been told to me, if you work and live in the State of injury, then the work comp case is to take place in that State. Not just because the employer is based out of another Stats such as CA stated here. But, I have been known to be wrong from time to time.

Now for the denial, your attorney needs to fight for your rights on that. Talk to your attorney, and ask what the plan of attack is now.
Reply's are intended solely for informational purposes. They are based on personal opinions, experience, or research and are "not to be taken as fact or legal advice", otherwise, always consult an attorney or a doctor.
 
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#3
no boy, you are correct.
generally its where injury occurred or worker's residence that determines jurisdiction.
california has a bit more specific requirement:
if the hiring was done in california then they can exert jurisdiction.
but that appears moot at this point as claim is 4+yrs old.

they can be allowed to lie because it has not been challenged in comp court.
No, california does not use peer review.
It's only legal if it is not challenged in comp court.
the pain guidelines were added in may of 2009
http://www.dir.ca.gov/dwc/DWCPropRegs/MT...ations.htm
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#4
My injury took place in CA. The company I worked for was unique in that I was hired by them in CA, but lived in Denver as a "resident rep." Because the company is based there and because the injury took place there CA took jurisdiction.

I've scheduled a conference call with my attorney for next week and lying on their denial will be a key point I will bring up. However, I feel as though since I took Future Medical that my attorney really will no longer will fight for me. I get that since I took future medical that there will not be a settlement and therefor he will not get paid, but it's so incredibly frustrating.

Maybe someone can clarify some things for me because I just cannot believe because of this injury I am permanently disabled, have chronic pain, have to use a special cushion everywhere I go because i can no longer sit without it, cannot use my degree that I was in the process of getting at the time of injury, and can no longer have children that there will not be any monetary compensation to help me at least cover my student loans??

I still am having issues getting the insurance company to pay for some treatments that they should be paying and I am having to pay out of pocket. I'm also still waiting to be reimbursed for out of pocket expenses from 2 years ago (which I submitted the receipts to my attorney who said he would take care of it 8 months ago.)

I'm really not sure what to do because I don't know if my attorney just plain sucks or if he is great and it's just the system that sucks.

Can someone help me to understand the process a bit more? I was initially given 14% permanent disability and I was paid something like $5,000 for that. I was given temporary disability for 6 months, but then the payments suddenly stopped because my doctors were saying that they didn't know what was wrong with me since the surgery didn't work. I was then referred to my current doctor, who I actually had seen for several months prior to my surgery, for pain management. My current doctor referred me to see a therapist because I fell into a deep depression after my orthos told me they could do nothing more for me. I just can't bear the thought of living the rest of my life like this in chronic pain.

I am so very close to being on the street and living out of my car, which I never thought would happen to me. I worked for major record labels in their marketing departments for the last 15 years until I was laid off. I lived a middle-class life, had a savings account, left the country once a year for vacation, and now...I have nothing. I can't work because of the pain, I was in the middle of getting my BA in 3D Animation when I was injured, but my doctors were convinced the surgery would fix me so I pressed onward and graduated. A year later I had my surgery, and it's now a year after surgery and I can no longer use my degree because I cannot sit. I cannot collect unemployment because you have to be fully able to work. I applied for SSD 6 months ago and I have been jumping through all of their hoops, but I still do not have a decision from them. My savings is gone and I really don't have any place to go where I could stay. I've sold everything that meant anything to me, been taken to collections by SallieMae (student loan company), my credit is ruined and used to be perfect, and to top it off I can never have children because the pressure on my "tailbone area" is too much to bear even when I'm constipated. There's no way I could ever carry a child. I'm also depressed and currently relying on friends who have been kind enough to give me food and a place to stay for the time being.

This is what this injury has done to me and all I'm getting from the insurance company are my pain meds paid for (not my anti-depressant mind you or my therapy sessions covered!), regular office visits paid for, and $5,000??? Really??

Advice, info, help, please?
 
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