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Problems with Insurance Company after Surgery
#1
Hello everyone.

I have a workers comp claim in Tennessee that has been ongoing since October of 2010. I was misdiagnosed originally and told nothing was wrong with my knee.To make a long story short, in February I had surgery on my left knee to reattach part of my femur bone with nail sutures. It had chipped off and was floating in a pocket of fluid. I don't remember the technical name for the surgery off the top of my head. It was an arthoscopic knee surgery, though.

I had months of recovery time and about two months of physcial therapy. During that time I developed a staph infection in one of the incisions due to the inside stitches not dissolving. I had three doctors appointments before the doctors decided my incision was indeed infected.

Within the last four weeks I returned to work for the first time, the first week being light duty with no squatting and the following weeks full duty. I have been working my job regularly, but my hours have been reduced since I returned to work.

Now to my currect predicament...

Within the past three weeks, I have begun experiencing more and more pain associated with the knee I had surgery on. I have had communication problems with the insurance company and my doctor throughout this entire ordeal, but it has gotten much worse. Last week was devoted to contacting my case manager, doctors office, and insurance company concerning the pain I am experiencing.

I was told by my case manager upon calling her for the second time that she was no longer handling my file. She instructed me to contact the doctors office. After two days of calling the doctor's office I finally reached the nurse who told me I could not get an appointment before my scheduled visit on July 6th. I explained I was experiencing more pain than I expected upon returning to work, that it was affecting my work habits, and I even have pain when not using my knee. She said that I might just have pain associated with my surgery indefintiely. She perscribed me Ultram, which I had previously taken during my recovery time, and told me to contact the insurance company about seeing the physicians assistant.

I called the insurance company and left a message with the guy handling my claim on Thursday of last week. He did not call me back on Friday.

I want to get another MRI done on my knee to try and figure out the cause of my pain and swelling. I had several xrays taken of my knee and the doctors told me there was nothing wrong with my knee. I was misdiagnosed until they did a MRI. I was told by a friend who is a nurse to visit the ER this coming week. I am worried with all the stipulations of workers comp, that the insurance company will not pay for the visit.

I have not gotten a lawyer through any of my struggles with the insurance company, despite the fact that I could not work either of my two jobs during my recovery time and have gone into debt as a result of this injury. I also lost my health insurance through my job because I could not make the monthly payments required during my recovery time.

I am sorry this has been such a lengthy post, but I am at my wits end. Does anyone have any suggestions on what to do next? Should I go to the ER? Will the insurance company cover my visit to the ER? I need to keep working so I do not get evicted haha... but it's becoming harder and harder with all this pain.

Thanks for your time and any suggestions,
Donovan
 
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#2
Welcome to the forum!

First, we need you state as work comp is state specific.

Second, I would think it is time to start looking for an attorney. The insurance company has attorneys on their side to and you also need need one.

If the pain get to bad then go to the ER, tell them it is work comp and give them the name of the insurance company.

I was injured in 2005, a left knee injury, it was 5 months before I received medical treatment in the way of meniscus surgery which was a failed surgery. My knee did not track correctly after sugery. The delay of medical treatment lead to problems with the other knee along with the altered gait lead to issues with the lumbar spine.

I had a total knee replacement in 2008, since the injury I've had 6 surgeries.

Yes, I still have problems with both knees and will need a total knee replacement of the other knee in the future.

Bodybuilder is another injured worker on this forum with a knee injury, she is also a surgerical nurse. She had problems with infection after surgery, long story. She is on vacation right now but I will send her an e-mail and ask her to respond to this thread.
 
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#3
in workers comp the employer/carrier controls treatment.
you'll need a medical referal for an MRI
you can request a change of physicians.
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
(06-26-2011, 06:37 PM)Bummer Knees Wrote: Welcome to the forum!

First, we need you state as work comp is state specific.

Second, I would think it is time to start looking for an attorney. The insurance company has attorneys on their side to and you also need need one.

If the pain get to bad then go to the ER, tell them it is work comp and give them the name of the insurance company.

I was injured in 2005, a left knee injury, it was 5 months before I received medical treatment in the way of meniscus surgery which was a failed surgery. My knee did not track correctly after sugery. The delay of medical treatment lead to problems with the other knee along with the altered gait lead to issues with the lumbar spine.

I had a total knee replacement in 2008, since the injury I've had 6 surgeries.

Yes, I still have problems with both knees and will need a total knee replacement of the other knee in the future.

Bodybuilder is another injured worker on this forum with a knee injury, she is also a surgerical nurse. She had problems with infection after surgery, long story. She is on vacation right now but I will send her an e-mail and ask her to respond to this thread.

Thanks for the response. I stated in the first paragraph that I am located in Tennessee. It was a long post though haha... I understand that you missed it.

I have put off talking to an attorney up until now because I have had decent luck handling the situation on my own. I am growing more and more tired of getting the run around from the insurance company and the doctor's office. I just want to be able to return to my normal life pain free, but it looks like that might not happen anytime soon.

I am worried about visiting the ER and getting billed for it or the insurance company dropping my claim because I went outside their boundaries. I wish someone had told me prior to the surgery that I might experience pain associated with my knee for the rest of my life. It is hard for me to function as a person when every second I am experiencing some form of pain in my knee. It is really affecting my quality of life.

I was told by my friend that if I visit the ER the doctors office will require that I come in for an appointment within 3-5 days. If they do not schedule me an appointment I will have a real legal case. I don't understand why I have to take such drastic measures just to get the doctor to look at my injury before my scheduled appointment. Sad

I wish you the best of luck in your own recovery and thanks again for your input.
(06-26-2011, 07:17 PM)1171 Wrote: in workers comp the employer/carrier controls treatment.
you'll need a medical referal for an MRI
you can request a change of physicians.

I tired that route when I had the infection. The insurance company case manager told me that I could not get a second opinion or change my physician at this point in my recovery. Was I lied to?

 
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#5
I understand your thoughts on the ER, with my injuries and being denied medical treatment I have never been in the ER for my injuries. I have just toughed it out at home, taking more meds, massage. ice/heat, & no sleep.

My most recent injury was last summer when the work comp doctor injured the neck while doing an exam. A migraine lasting over 30 days followed that exam. Doctors now tell me they are suprised I did not stroke out during that time and I should have been in the hospital. (We did not know until later that I had a large herniation of C5-6 displacing the nerve roots and putting pressure on the spine)

Guess there is a time when one should visit the ER.
 
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#6
"Under Tennessee law, the employer or insurance carrier is not required to offer a second panel of physicians or a second opinion. If asked, however, the insurer or employer MAY provide a second panel. An employee may always seek a second opinion or obtain treatment with any physician at his/her own expense. However, only the restrictions of the authorized physician must be followed by the employer.

If you have problems with any part of your claim, the state has a Benefit Review Program that assists employees, employers, and insurance carriers with resolving disputes with workers' compensation claims. The Tennessee Department of Labor and Workforce Development's Workers' Compensation Division can be contacted at 1-800-332-2667 or 615-532-4812.

http://www.tn.gov/labor-wfd/wcfaq.html

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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