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Settlement and Buy Out in Cali...

The Pain Dr is in their network....this has been ongoing for 6 months now. She stated she has never received any request...I have 3 fax numbers for them, and she did give me her personal fax that goes straight to her computer. So we shall see...
It has never been an issue before living in Las Vegas where we are now. This new adjuster is just ridiculous!! I mean it.

Our old atty, now a judge, had someone take over his practice. We had tried in the beginning, a few years ago, to contact him and have him ask for settlement and such, no returned calls, nothing. So that is why I have been attempting to handle things. My husband was hurt in Northern California, Bay Area. His case was based at the Oakland WC Courts.

I was reading over CIGA's policies and such, and they do have the power to settle. I am wondering why they did not allow the previous adjuster to follow through. The last thing she told me, was that they were looking into the MSA and then she was replaced. This new lady is #17 on our case. My husband's case is almost 16 years old now.

I do have a question though. Even though he was deemed 100% permanent and stationary back in 2004, should his bi-weekly checks have gone up with the new laws? Reading over things, it looks as though they should have "upped" his money a bit over the years. The IC gave the old atty his money, and they took that out of my husbands check and have done so for 11 years now. Any thoughts to this?

I really appreciate you all for your help and taking the time to help us. My daughter, who is also disabled with debilitating epilepsy, has been homeschooled now for the last 5 years, and her seizures are getting worse.....taking care of her and my husband has been pretty hard on me physically over the years.
I was told years ago, the IC was supposed to pay me for taking care of him since the Dr said he needed 24/7 care and they will not pay for a CNA or Nurse anymore. Back in 2004-05,the IC paid for a CNA, then they stopped paying the company, and he was not allowed to come back, thus my husband has just had me taking care of him before that and now since. Any truth to this?

Also, gosh I am sorry for rambling, the surgeon my husband has seen for the past 11 years, said and I quote..."I have never seen anyone so incredibly medically neglected in all my years. I swear they are trying to kill you." Is there anyway at all to possibly sue the IC? For medical neglect or something? The new adjuster said that he is not allowed to see the surgeon anymore, he is the one giving him his meds, they did a PEER TO PEER with him last month and also did a urine test on him to be overnighted back. I am just seriously confused to why she is doing all this to us again. They treated us AWFUL in the first few years, then it got a bit better. Now this new adjuster is actually WORSE than in the beginning.

Thanks again!! I look forward to hearing from you all.
Big Grin

(12-07-2014, 04:07 PM)California_Help Wrote: Hi,

Your claims adjuster does not have the right to deny treatment or medical care. Has your husband requested a link to their MPN? If there are no MPN doctors that are in the state you moved to, your claims adjuster must allow you to chose a doctor who will accept CA work comp.

You stated your husbands attorney is now a judge. Did he transfer your husbands case to another attorney or is he still the attorney of record? If he is, then he is obligated to continue to represent your husband. If he no longer has an attorney I recommend contacting an information and assistance officer at the board your case is at and ask for help with this issue. I would ask if you can file for an expedited hearing and do the hearing via phone conference.

Let me know if you need help. I do not want your husband to be in a situation of running out of medications. Please take your husband to an emergency room if he begins to go through withdrawals and give the hospital all of his work comp and claims adjusters info to bill. This is my suggestion, but I would check with his doctor on the best course to take.

Can I ask you if his case is in Northern or Southern CA?

Big Grin
Here is to Strong Women! May we Know Them, May we Raise Them, May WE BE THEM!!

You need to make sure your husbands doctor is requesting it on the new RFA form. You also need a copy of the RFA form request AND fax confirmation of when it was sent. It is illegal to ignore a request with a doctor who is within the MPN. So on review a claims adjuster can ignore requests from doctors outside of MPN, but not on correct, current RFA form. You need fax confirmation from doctors office to file for a hearing OR to write a UR complaint. I suggest you go on the states webpage and write a UR complaint sending copy of RFA and fax confirmation. You can send a copy to this claims adjuster supervisor, but that may make things worse.

A claims adjuster has no right to tell your husband he cannot see a doctor UNLESS he is no longer in the MPN. Check your husbands MPN to see if he was removed. It happens.

Also, peer to peer is being done by utilization review, not your claims adjuster. Read the UR denials and have your husbands doctor APPEAL the denials. He has 10 days from the date of the denials. Also, if your husband gets a UR denial, read through it, and request an IMR review. Come back to this site when this happens and I will help you with it.

You also wrote his home health was cut off and you have been doing it. He will only get home help IF your husbands doctor requests home help, with a RFA and a LOT of back up that shows it is warranted. It will then go to UR. It denied there is 10 days to appeal it. Your doctor needs to appeal ALL denials. You can also request an IMR paper review. Again there is a time limit for this.

Please, please fax your husbands attorney or send certified mail return request that he needs a phone appointment. Actually your husband needs to request this as it is his attorney, and they may not talk to you unless your husband has given written authorization. I suggest writing a list of questions for the attorney in advance and include it in the letter. I would also just call today for a phone appointment. It is illegal to abandon a client. If the attorney continues to ignore, you can contact the CA state bar for assistance, but I would use that as last resort. Start a paper trail asking for phone appointment and state phone contact has been not responded to. You cannot file for a hearing if represented. I wonder if a letter to your husbands former attorney(currently a judge) about the lack of response of current attorney would get some butts in gear.

I will try my best to help you, but I am not an attorney, just an injured worker. I will check back a few times a week for this thread.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.

Please let me know if the attorney is still refusing to communicate. I would suggest hiring another one if it continues. I can provide you with a few links if you need it.

The above is a current case about home help denial. I am not sure if your husbands was denied legally. There is a ne request process put in place and his doctor can request it again now.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.

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