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WC and Private Insurance
#1
I was hoping someone might be able to help me. I live in California and I am a graphic designer, I have an ongoing workmans comp case which was started in Nov. 1999 (at 11 years right now I am 48 years old.) I have been diagnosed with bi-lateral carpal tunnel, bi-lateral cubital tunnel, bi-lateral shoulder problems, & 3 disc bulging in my upper neck (and with all this loss of use, grip and dexterity and constant numbness). I have had surgery on both hands and elbows though not all have had great outcomes. I have not received any relief from my last surgery and am now actually worse than prior to surgery. In 2006 I settled with the WC carrier with a small award and lifetime medical. At that time I had both carpal and left cubital done they rated me at 50% disabled. They tried to buy out my medical but attorney insisted I get lifetime medical. My meds have averaged $525.00 per month. After each surgery I have gone back to the same job. My last surgery I had done June 2010 was not successful and I have had considerably more problems. I was off until August of 2011 because of pain and numbness and loss of use. Since my surgery last year the WC has been denying all tests the Dr has ordered (MRI’s on shoulders, neck and arms, PT and a tens unit). Dr. has filed numerous rebuttals from the determinations they have made and they deny them stating there is no proof showing I have any problems and no test to back up claims. I had a QME done March 2010 and Dr stated all my problems and said I will need my shoulders taken care of soon. I have called my attorney several times and talked to his aid with no help. Today I called and talked to her and she says now they have seen the Dr’s filings and the denials from WC company they say they are going to contact the QME Dr. for clarification. Then out of the blue she says to me "to bad you don’t have private medical insurance". I tell her I have had private medical insurance all along she tells me to go to KP and tell them I am in pain and not mention the WC case. She said they are MRI happy and will do it. I feel that this is dishonest and I don’t want my private insurer to come after me for a bill WC should be paying and WC to say you went to your private Dr. now we are not liable. Sorry the post is so long but I have been stuck in this vicious cycle for way to long and not sure how much longer my employer will deal with my restrictions and problems.
 
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#2
(11-22-2011, 04:34 PM)mickeyluvr63 Wrote: Then out of the blue she says to me "to bad you don’t have private medical insurance". I tell her I have had private medical insurance all along she tells me to go to KP and tell them I am in pain and not mention the WC case.

That would be Insurance Fraud.

As to the rest of your issues (the QME, etc), it would be wise to ask your attorney to request a hearing. Either side can do so if there are medical disputes.



DISCLAIMER: I am not an attorney. While drawing from my professional training and experience in law enforcement and as a former Paralegal, no comments offered should be considered as legal advice.
 
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#3

if your condition is worse then your prior rating, you may have had a recent aggravation from you job and you would be entitled to file a new claim for any increased disability. discuss it with your doctor.
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
Thats what I told her and she said just tell them you woke up and it was hurting. I said but it didn't just start it has been going on forever. She tells me if I don't I could be waiting another year to get any help. Needless to say I dislike this aid ALOT.
 
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#5
(11-22-2011, 06:08 PM)mickeyluvr63 Wrote: Thats what I told her and she said just tell them you woke up and it was hurting. I said but it didn't just start it has been going on forever. She tells me if I don't I could be waiting another year to get any help.

This person is asking you to perpetrate a fraud on the private insurance company. Furthermore, if you visit your Dr. and state (on record) that you just woke up hurting (i.e., pretty much stating that it's not a work injury) that will be used against you to deny coverage under WC.

Don't open that can of worms.

Quote:She tells me if I don't I could be waiting another year to get any help.

Not so. File a report with your employer, and ask them to implement a WC claim for you. It won't take a year to get medical attention.
DISCLAIMER: I am not an attorney. While drawing from my professional training and experience in law enforcement and as a former Paralegal, no comments offered should be considered as legal advice.
 
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#6
(11-22-2011, 07:09 PM)LeglEgl Wrote: [quote='mickeyluvr63' pid='140143' dateline='1321999684']
Thats what I told her and she said just tell them you woke up and it was hurting. I said but it didn't just start it has been going on forever. She tells me if I don't I could be waiting another year to get any help.

This person is asking you to perpetrate a fraud on the private insurance company. Furthermore, if you visit your Dr. and state (on record) that you just woke up hurting (i.e., pretty much stating that it's not a work injury) that will be used against you to deny coverage under WC.

Don't open that can of worms.

Quote:She tells me if I don't I could be waiting another year to get any help.

Not so. File a report with your employer, and ask them to implement a WC claim for you. It won't take a year to get medical attention.

Hi I now believe this is what is really going on everywhere! Just this week I got the same response from my attorney. I am really glad I saw your post and the answers you have received. I unlike you still cannot get surgery out of my (their) doctors; they are still denying them.

 
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#7
Quote:She tells me if I don't I could be waiting another year to get any help.

Not so. File a report with your employer, and ask them to implement a WC claim for you. It won't take a year to get medical attention.

When talking with the attorneys aid she stated they now have to get clarification from the QME Dr. She told me the attorney said they will not be taking this to court until they hear from the QME Dr. I dare not even broach the subject of filing another claim with my employer. I work for family business (19 years now) and from what I have been told they got in a major fight when I came back off Disability. One brother and his son wanted me to be let go. Needless to say I am walking on eggshells now and there isn't much work these days out there, let alone for someone with very, very limited use of there hands.

 
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#8
(11-23-2011, 01:16 PM)mickeyluvr63 Wrote: When talking with the attorneys aid she stated they now have to get clarification from the QME Dr.

Since they're waiting for some determination from the QME Dr., it appears that the old case may have been re-opened. Perhaps the attorney's assistant was making the suggestion earlier to encourage you getting medical care sooner rather than later.

Still, unless it's life-threatening, I wouldn't be attempting subterfuge by claiming under your private insurance.

DISCLAIMER: I am not an attorney. While drawing from my professional training and experience in law enforcement and as a former Paralegal, no comments offered should be considered as legal advice.
 
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#9
there is a difference between getting care thru your private insurance after it has been delayed/denied by workers comp.
you don't need to lie about the cause when care has been denied by comp.
the health care provider will file a lien against the comp claim and the liability issue can be resolved by the comp court at the time the claim is finalized.
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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