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CA WC total denial, covering medical...HELP, ADVICE, PERSPECTIVE?!
#1
It's been almost a year since my date of injury and WC initially denied my claim as a delay per QME/AME examination and determination, but before that could happen they denied the claim totally, instead choosing to base their decision for denial on the opinion of the first doc I saw. This was the only reason I hired an attorney.
Just recently medical treatment has been authorized by the ins company, but NOT compensation. Everyone is baffled, my doctors are confused and my attorney told me not to look a gift horse in the mouth...does anyone have any experience with something like this? They're trying to starve me out and I'm starting to lose my mind.
 
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#2
(06-23-2014, 05:22 PM)BrokenandBeaten Wrote: It's been almost a year since my date of injury and WC initially denied my claim as a delay per QME/AME examination and determination, but before that could happen they denied the claim totally, instead choosing to base their decision for denial on the opinion of the first doc I saw. This was the only reason I hired an attorney.
Just recently medical treatment has been authorized by the ins company, but NOT compensation. Everyone is baffled, my doctors are confused and my attorney told me not to look a gift horse in the mouth...does anyone have any experience with something like this? They're trying to starve me out and I'm starting to lose my mind.

If they are authorizing treatment, that makes me think your injury is now accepted. What did the AME/QME determine?

Have you applied for state disability and any LTD/STD policy (if you have one)?
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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#3
disability determinations are separate from ones for treatment liability.
you can file for a penalty if they have no evidence to support the denial. you can also file for an expedited hearing to determine disability payment responsibility.
you change attys at any time.
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
(06-23-2014, 07:21 PM)1171 Wrote: disability determinations are separate from ones for treatment liability.
you can file for a penalty if they have no evidence to support the denial.
you change attys at any time.

They are basing the continued denial regarding some petty issue with the AME, even after both he and another Dr. (Also a QME, but not pertaining to my case/claim) have both stated industrial related. The AME was subpoenaed for a deposition and even then nothing he opined changed, going as far as to have him preform another examination in the relatively distant future.

To change lawyers means dishing out close to 30% of whatever I get IF I get it. I don't really care about that too much, I'd rather be fixed and working, taken care of while I'm healing and get back to work.
 
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#5
atty fees are generally at 12-18%.
there is a single atty fee that would be shared among your attys.
the unreasonable delay of benefits are grounds for a large penalty. you're right; the court would have to agree that the denial is "petty".
see labor code 5814
http://www.leginfo.ca.gov/cgi-bin/displa...=5800-5816

apply for ssdi or sdi.
ask your doctor for a referral for counseling; emotional problems and depression can be a road block to successful recovery of any serious condition.

I'm not sure what other information/help we can provide.
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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#6
(06-23-2014, 08:54 PM)BrokenandBeaten Wrote:
(06-23-2014, 07:21 PM)1171 Wrote: disability determinations are separate from ones for treatment liability.
you can file for a penalty if they have no evidence to support the denial.
you change attys at any time.

They are basing the continued denial regarding some petty issue with the AME, even after both he and another Dr. (Also a QME, but not pertaining to my case/claim) have both stated industrial related. The AME was subpoenaed for a deposition and even then nothing he opined changed, going as far as to have him preform another examination in the relatively distant future.

To change lawyers means dishing out close to 30% of whatever I get IF I get it. I don't really care about that too much, I'd rather be fixed and working, taken care of while I'm healing and get back to work.

If the AME has written it is industrial, then your attorney needs to file for a hearing so you can receive TTD payments. I would discuss this with your attorney. The fact they are giving you medical treatment now should not be considered a Godsend in my opinion. The AME has deemed your injury is work related. They will continue to take advantage if your attorney does not request a hearing over your TTD issue.

It is not true that if you hire an attorney they will then take 30% of your award. It means they will split the 15% between two attorney's. I hope this helps you.

I think you should request a meeting with your attorney and discuss your TTD.

In the mean time you can apply for state disability.

Good luck to you.


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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#7
Thanks...This is actually helpful in more ways than one. Much much much appreciated.
 
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