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CA-Settling "Lifetime Medical"
#1
CA - awarded "lifetime medical" via compromise & release for liability, medical care would follow the scope of the AME report. At this point is it possible to go back into court and get a settlement of medical from them so I can just move on?

The IC agreed to follow the scope of the AME reports for followup care and treatment. The judge awarded it, IC subsequently disregarded AME report and has their hired denial (a.k.a. underwriting review arm) deny every request for actual treatment. They have played the denial game for so long I don't think I will ever get any actual treatment beyond a prescription bottle.
 
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#2
very rare for carrier/employer to buyout only the disability benefits and have to keep the claim open for medical.

No.
the comp court cannot price out your future medical needs or force the carrier to agree to an amount to buy it out.
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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#3
(07-10-2013, 12:37 PM)1171 Wrote: very rare for carrier/employer to buyout only the disability benefits and have to keep the claim open for medical.

No.
the comp court cannot price out your future medical needs or force the carrier to agree to an amount to buy it out.

Surprised at this reply. I see cases all over this board with "open medical," "lifetime medical." Problem in my case and I am sure in many others is lifetime medical means absolutely nothing if you can not get treatment.

California WCB is a joke to try to get anything done to move this along. I am still waiting for yet another AME eval that the judge ordered six months ago. Defense attorney is required to set it up since the judge ordered them to set it up with a specific doctor to stay within the IC MPN (which is an absolute farce since virtually none of these docs see WC patients). No dice. Still waiting.

I am willing to settle out the medical and go it alone since that is basically where I am at anyway. Why would it be so difficult to put a price on medical between the parties and just settle and close the claim completely? Shouldn't be such a big deal!
 
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#4
have you ever known the legislature or the legal system to make anything simple?


would you accept a $1?

so No you are not willing to settle and go it alone. you want a reasonable amount.
and that is the rub.
what is reasonable for you is not for the carrier. so it is not simple. it has to be fair to both parties that's why it's up to negotiation.


the legislature would have to change the Comp system to include the duties of fixing/setting future medical values. In some states they require arbitration but that is still different.
california could setup rbitraition panels to facilitate the negotiation on the value of a claims future medical...but they haven't and it's still involves a negotiation as the arbitor does not calculate the future value of a person's medical needs.

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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#5
(07-10-2013, 01:25 PM)1171 Wrote: would you accept a $1?

so No you are not willing to settle and go it alone. you want a reasonable amount.
and that is the rub.
what is reasonable for you is not for the carrier. so it is not simple. that's why it's up to negotiation.


That was my original question in my first post... can medical be settled, and yes I fully understand it would be a "negotiation" between both sides. NO... I wouldn't accept $1. However, at this point I am want to settle and close the claim and go it alone since the IC will not authorize any treatment, will not schedule AME appointments that were ordered by a judge etc.

Going to the pain doc month after month, taking fists full of meds to keep the pain at bay is not treatment. It's torture. I guess I could just kill myself and that will make the IC super happy.
 
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#6
make a demand and see if they are interested.
they are not required to negotiate or buyout the rest of the claim.
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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#7
(07-10-2013, 01:11 PM)SickOfTheProcess Wrote:
(07-10-2013, 12:37 PM)1171 Wrote: very rare for carrier/employer to buyout only the disability benefits and have to keep the claim open for medical.

No.
the comp court cannot price out your future medical needs or force the carrier to agree to an amount to buy it out.

Surprised at this reply. I see cases all over this board with "open medical," "lifetime medical." Problem in my case and I am sure in many others is lifetime medical means absolutely nothing if you can not get treatment.

California WCB is a joke to try to get anything done to move this along. I am still waiting for yet another AME eval that the judge ordered six months ago. Defense attorney is required to set it up since the judge ordered them to set it up with a specific doctor to stay within the IC MPN (which is an absolute farce since virtually none of these docs see WC patients). No dice. Still waiting.

I am willing to settle out the medical and go it alone since that is basically where I am at anyway. Why would it be so difficult to put a price on medical between the parties and just settle and close the claim completely? Shouldn't be such a big deal!

     I can so relate.  Life time medical means nothing in CA, now.
 
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#8
(12-27-2016, 03:15 AM)SacGirl Wrote: I can so relate.  Life time medical means nothing in CA, now.


As med costs rose astronomically and cost shifting became pervasive, they finally overwhelmed the blank-check provisions of work comp med coverage. now utilization review, evidence based guidelines, and extensive fee schedules attempt to hold the line.
the political power of big business and dwindling effectiveness of labor have left workers all over the country with less of a safety net against serious injury and disability.
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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#9
Lifetime medical patients in CA must still be subjected to the UR and IMR process.

The biggest problem I see is doctors are not well versed in the guidelines. They appear pretty simple when you read them the MTUS however most chronic, complex long term conditions do not fit within the MTUS and chronic pain guidelines and when this happens doctors can use ODG or ACOEM guidelines. The problem is most doctors in CA WC either do not know this or have the guidelines and/or do not get paid to take the time to look them up. If you go to a specialist at a major university for example, chances are high he will not know what MTUS is or even where to find it.
UR and IMR are using guidelines incorrectly often times as a means to deny, so if the treating doctor does not check the guideline used to deny they can be taken advantage of this way.

 In CA doctors also do not get paid for record review or for writing UR internal appeals or for sending in an IMR.

So....if CA doctors within MPN's are not trained on these guidelines, and do not get reimbursed for appealing denials how in the heck is a CA injured worker supposed to get a fair shot at appropriate treatment? This system looked good on paper when SB863 was written but I knew this was going to be a big problem when I did not see any type of reimbursement in the bill for doctors to do UR and IMR.

While your AME no longer has control of treatment disputes, you can still send in a copy of his report when you are appealing a UR denial. It is much easier to do an internal appeal with the UR company than to deal with IMR. Many are not appealing their UR denials within the UR company directly and just going to IMR. This is a mistake IMO because IMR has a 95% denial rate.

If your WC doctor does not send it treatment guidelines and does not appeal UR denials it may be very difficult to get treatments approved. You can look up guidelines yourself and appeal the denials yourself. I do it for myself and have shown others how to successfully appeal them. So there is a way to get treatment, you have to do some work and you also need your medical records, and your medical condition and records must reflect the request is warranted. If you are representing yourself you should be copied on your medical records.

If you have other insurance that will cover your injury and you are having difficulties with treatment denials I recommend to try and negotiate a compromise and release of your medical.

If you have other medical coverage and receive a denial through work comp I recommend seeking treatment through other insurance if they allow it and many are.
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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