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Partially Denied Multiple Body Parts Claims. Please HELP!
#1
Hi all,
It’s sad that after all that long & hard working years for the employer and paying into the system, when it came to injury, the first thing my employer did was turning their back on me then trying to cover it up with all kinds of paperwork that they made me sign decade ago! Then come the doctors, the lawyers, the SSA, the EDD, etc., they were spinning me like a piece of meat with no regards, it’s very sad! Being a single parent with little education, raising 2 under age children with this condition, I think you know what my life is like!

Enough for whining, I have a question, but I have to explain it in detail so you have better understanding.

State is CA, I got injuries with multiple body parts, the shoulder rotator cuff tear, the Tennis elbow, the neck sprain, and the C-Spine due to herniated disc C3-C7. Everything has been going OK with treatments: rotator cuff surgery, chiropractor, PT, acupuncture, psychiatric, home therapies, etc. EXCEPT the IC denied Herniated Disc, said it’s not part of the claim. Here is the story:

When I first reported my injury in 2012, I reported everything above and an upper back pain, the IC Doctor diagnosed me with Strain Thoracic Spine T3-T5. And even when I changed doctors, no one bothered to re-diagnose my “upper back”, they kept what the IC doctor said about my upper back. Two years later, because they said they had to treat one thing at a time, after the rotator cuff surgery and other therapies, it’s time to treat my back, they ran an MRI, it came out NEGATIVE, they said nothing wrong! I was stunt, how could it be, the irritating pain like someone poking me with a pointed object that I have carried on my upper back for years came from nothing!? My PTP suspect it a Cervical-Spine instead. He requested an MRI C-Spine, IC denied, said it’s not related. The PTP suggested I go ask my family Doctor for an MRI. I did, the MRI came out POSITIVE with MULTILEVEL Herniated Disc from C3-C7!!! But the IC still denied it!

Now I know, it’s just between the “C” and the “T”, I wish I knew then, but even if I did, wouldn’t I be smarter than those pathetic doctors!

I saw the Panel QME twice and he put me on PS, he did not have my C-Spine MRI in his possession during the evaluations, he stated that I do have a work-related neck sprain. My attorney sent him my MRI; he said he stayed with his decision, the MRI means NOTHING to him.

I am on PD, SDI, trying to apply for SSDI…denied twice, food stamp…denied! Also when I saw my family doctor for the C-Spine MRI, he denied my treatment because he said that it is “work-related”!

Very frustrated, don’t know what to do anymore!  Please help!

Sorry for the lengthy post, any question, please ask.

Thank you for your kindness!!!

I wish I found this forum sooner!!!


 
 
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#2
I assume you mean about getting the QME opinion changed.
since you are represented there is little you can do personally.
your atty could depose the doctor and see if under direct examination there is variation to his opinion.
depending on the result of the deposition your atty can request a trial and let the judge decide.

barring a trial a settlement of the issue could be attempted.
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
There are a few things your attorney can do as 1171 wrote.

1. He can ask your primary treating doctor to write a rebuttal to the QME report. Your attorney needs to do this in writing, and your doctor gets paid for the report. Your attorney would then take the two reports to a judge and let a judge decide on any denied body parts.

2. He can write a letter to the QME and provide him with additional information (if it was not provided the first time) and ask he write a supplemental report.

3. He can depose the QME. Many applicant attorney's will not do this is they have to pay for the depo upfront.

If you want to be a little proactive, this is what I would recommend:

1. Call your attorney's office and ask for the QME report(s), a copy of the cover letter(s) and exhibit list(s) that were sent to the QME. I would then review the exhibit list and see if the QME doctor received all reports that prove this injury. I would then compare the exhibit list (list of records sent to the QME) an go through the QME report and check off every report on the list as it was mentioned or listed in the QME report. Then you can see if this QME was actually sent all of the records on the list. It may be difficult to do this if you do not have your records. Some applicant attorney's offices send records directly to a QME, but I would say a large majority add it to the defenses list and allow the defense to send everything. I have found many times not everything is sent, and it can be done strategically. This may or may not have happened in your case, but if you have records that state you reported the body part early in your claim I would make sure the QME got the records. You may have just gotten a defense QME. In this case it would not matter what records were sent. In this case your attorney has the options I wrote about above.

2.If going through records etc is too much for you, then I would recommend making an appointment with your attorney, either phone or in person and ask what he is going to do about the denied body part. I would do this gently and start off by thanking him for all of his hard work etc etc. As 1171 wrote you have an attorney, and there is little you can do, but if he does not take action you can try to find another attorney or represent yourself. It is also possible that the judge would rule in the insurance favor.

In the mean time I suggest going back to your private insurance doctor and let him know that part of your injury is denied. You are allowed to get treatment through private insurance for a denied body part. You can change doctors if he does not help you. Has anyone stated you need surgery?This comes to my question of do you want to fight this? I don't know how your medical treatment in work comp has been, but I have found private insurance is so much better. However if you need a surgery and have high co-pays this is also something to look at how good of coverage you have with insurance.

If you want to be more proactive in your claim start getting copies of your medical reports (if you have not done so already). Every time you see your doctor ask the person at the desk to print out a copy of your last report. Getting all of your previous records can be costly, but some offices do not charge for it or charge very much. You can ask your attorney's office and/or doctors if there is a way to get your name on the cc'd list on your doctors reports, then you get them right away. It is always a good idea for injured workers to have copies of all of their doctors, physical therapy, MRI's etc. Get some paper legal files and organize by date, so once you get a new report it goes on top. I also recommend to do this for any UR and IMR determinations, and keep the envelopes from the UR denials. You can use these reports to appeal UR denials as well. This is another reason why injured workers should have a copy of their records. Doing this is definitely not for everyone. If this is something that would overwhelm you, then I would advise against it.

I assume you were denied food stamps due to income? Do you have an attorney to assist you in appealing the SSDI denial? If not I would hire one ASAP and I would recommend against the tv advertising ones like Bender (JMO). If your SDI runs out I would recommend applying for SSI (supplemental security income) and food stamps immediately. You may qualify for things like line help (not sure). I will place a link that lists a lot of resources. This organization does not deal with work comp issues but they have a great list of resources like food banks, line help (discounts in utilities) and housing. You may qualify for some other resources and you can always go to a food bank.

http://www.patientadvocate.org/NURD/inde...=uninsured
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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#4
California, again, thank you!

I have lots of stuffs to straighten out with my PTP and my Atty in regard of what my body parts that are and aren't accepted according to the PQME reports. His 1st report was on 5/14, my C-Spine MRI was on 11/14, his 2nd report was on 1/15, and his Supplemental report was on 3/15. It seems he has everything EXCEPT my C-Spine MRI in his 2nd report, my ATTY sent it to him, but he disregarded it in his sup. report. Before meeting the PQME, one of the case managers told me that he is either for me or against me. And dawn she's right, after my first 10 minutes meeting the PQME, I knew right a way which side he was on! So the reports didn't surprise me much!

I don't have private insurance, it was cut off immediately after I filed WC. I have to apply medi-cal. And yes I will fight this to the best of my ability!

I have to be more proactive, have been naive for too long!

It looks like I will have a surgery on my elbow soon.

Yes, I do have an SSDI Atty., and yes, I already try to get SSI going, because we have faced eviction notice from the landlord, and utility shut off in the past, it doesn't seem to get any better. Your link seems to be credible, I will surely go thru them ASAP.

I do have my first Status Conference next couple of months. What normally happens during this conference you know? Should I be prepared? For sure I will meet with the Atty prior to that date.
 
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#5
(07-26-2015, 12:52 PM)1171 Wrote: ......
barring a trial a settlement of the issue could be attempted.

Hi 1171,
Thank you for your reply, and sorry can you please explain what this sentence means?
 
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#6
if the choice is not to go to trial, then the dispute can be resolved thru a negotiated settlement.
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
Your attorney should be prepared for the hearing. Do you know what the issue is, if not I would put in a call beforehand to your attorney.

Where to look in the QME reports is the last few pages. It will state what body parts he rated. I would contact your attorney if you believe something is missing.

The link I provided should have line-help resources (help with utilities). The Salvation Army may be able to help with utilities too. Please take advantage of food banks if you need it. Some people do not go because they are embarrassed but there is no reason to be. It is there to help people in your situation, and especially for those who have children.

Good luck to you with your surgery. If you will need help at home after surgery, discuss home help with your doctor.
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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