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Getting Frustrated
#1
Hello everybody. I want to get your opinion on what's happening with my case in California. Thanks in advance.

In October of 2013 I slipped and fell during the scope of my duties. I reported the incident to my employer right away and filed a claim a few days later. My employer sent me to their medical network facility(doctor) for my initial exam and treatment. I went there three times and was diagnosed with sprains to my cervical, thoracic, and lumber spine along with shoulder pain.  I asked my employer if I could go to a closer medical facility of the same name (U.S. Health Works) since I had just moved. The answer was NO. That's when I decided to get an attorney(July 2014). My attorney told me to stop going to that medical facility and set me up with his own medical facility.( My claim was then denied due to me getting my own attorney and not going to their doctor.)  I had extensive therapy and treatments along with tests, x-rays, and an MRI with my new doctor. It turned out that the MRI showed 3 disk bulges with root nerve contact in my neck and an L4/L5 bulge with root nerve contact in my lower back. My toes are numb and so is my hand/fingers. I was diagnosed with shoulder impingement too. I was going for therapy and treatments 3 times a week until July 2014 and that's when a curve ball was thrown at me. My attorney was arrested!! What? Yes, arrested. I immediately attained a new attorney and my case was accepted due to the circumstances. It took 6 months for my records to get transferred(Dec 2014) and get a new primary doctor( In their Network) and to begin treatment again. Since my new doctor had my medical records now, he continued me on medications and referred me to have an epidural in my neck. The insurance authorized it and soon after I had the injection. I had my AME on June 22, 2015 and have not received the results yet. I have since been referred for shoulder surgery and am currently waiting for a date and I am also waiting for another epidural in my neck and my first epidural in my lower back. Here's the thing...the insurance company is waiting for the AME report to authorize any further procedures. So that's where my case stands. Oh yeah, my work restrictions are light office desk work with the ability to sit and stand at will( since Dec 2014) My employer has yet to offer me work and the status report from my doctor says if no work is offered then I am to be considered Total Temporarily Disabled. I have not received any TTD payments since my date of injury. I am in a financial mess and unable to pay my child support obligation.(thank God my family is helping my kids though.)  Sorry about the long story but it is complicated...
 
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#2
if their network doctor authorized your time off work they should have started TTD.
if so they are in penalty situation and your new atty should file.
since you've been off 12 months you should file for ssdi.
your child support payments can be deducted from any settlement.
the future course of your claim depends on the AME opinion.
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
(09-06-2015, 11:20 AM)1171 Wrote: if their network doctor authorized your time off work they should have started TTD.
if so they are in penalty situation and your new atty should file.
since you've been off 12 months you should file for ssdi.
your child support payments can be deducted from any settlement.
the future course of your claim depends on the AME opinion.

I didn't use their network after I attained my first attorney. My first pcp put me completely out of work Dec 18 2013, but since my claim was being denied I didn't receive TTD payments. On Dec 19 2014 My new pcp (their network doctor) gave me work restrictions and said " If modified duties cannot be accommodated by this employer, then this patient would be considered temporarily disabled from regular work and a separate off work order is not required." My attorney has been calling the insurance office but about my TTD but is not getting a response. Now about ssdi, I was denied. At the time it was when my records were in chaos and couldn't be found so the decision was made without any of my medical records. I might apply again since I have them now. I'm going to ask about the penalty, I read that too on the DWC site. My attorney also mentioned requesting a hearing.
 
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#4
Hi injured 72,

Yes your situation is complicated.

Did you call your employer and ask if they can accommodate your restrictions? (Since you have an attorney I suggest discussing this with him first.) You wrote your doctor stated you are TTD if your employer will not allow you to return to work with restrictions and why I am asking.

Did you apply for state disability (not SSDI)?

There was a time limit to appeal your SSDI denial and if you did not do it in time you may need to start the process again. I suggest hiring a SSDI attorney to help you. They will take a portion of your back payment, but it is worth it (IMO). I suggest calling SSDI attorney's but not the ones you see on tv like Bin---and Bin---. Did you qualify for SSI (supplemental security income)? I would also look into Cal Fresh (formerly food stamps now a credit card) to help since you have children.

I can see why your insurance carrier would not pay your TTD if you were being seen by a non MPN doctor, but you are now in network so they should comply. They may be waiting on the AME report. Your attorney should be doing more than calling and asking about your TTD, he should follow up in writing and file for an expedited hearing and ask for penalties and sanctions (JMO). He has been your attorney since July 2014. I think it is time he take action. I recommend making a phone or in person appointment with him to discuss your TTD. Most boards have about a month or so wait time to get an expedited hearing.

It was wrong for the insurance carrier to tell you can only be seen at US Healthworks. After 30 days you can see any doctor on their MPN.

The AME can comment on future medical treatment but AME's can no longer approve or deny medical treatment. So if your AME writes he does not recommend shoulder surgery it does not mean you cannot get it. Treatment requests are now subject to UR and IMR (if the claims adjuster does not approve the request). AME's can make decisions on if your condition(s) are work related.
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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#5
(09-06-2015, 05:50 PM)California_Help Wrote: Hi injured 72,

Yes your situation is complicated.

Did you call your employer and ask if they can accommodate your restrictions? (Since you have an attorney I suggest discussing this with him first.) You wrote your doctor stated you are TTD if your employer will not allow you to return to work with restrictions and why I am asking.

Did you apply for state disability (not SSDI)?

There was a time limit to appeal your SSDI denial and if you did not do it in time you may need to start the process again. I suggest hiring a SSDI attorney to help you. They will take a portion of your back payment, but it is worth it (IMO). I suggest calling SSDI attorney's but not the ones you see on tv like Bin---and Bin---. Did you qualify for SSI (supplemental security income)? I would also look into Cal Fresh (formerly food stamps now a credit card) to help since you have children.

I can see why your insurance carrier would not pay your TTD if you were being seen by a non MPN doctor, but you are now in network so they should comply. They may be waiting on the AME report. Your attorney should be doing more than calling and asking about your TTD, he should follow up in writing and file for an expedited hearing and ask for penalties and sanctions (JMO). He has been your attorney since July 2014. I think it is time he take action. I recommend making a phone or in person appointment with him to discuss your TTD. Most boards have about a month or so wait time to get an expedited hearing.

It was wrong for the insurance carrier to tell you can only be seen at US Healthworks. After 30 days you can see any doctor on their MPN.

 I know you are awaiting shoulder surgery, but if they start recommending a spinal fusion please get a few other opinions before doing a fusion. You have the right to get a second opinion.

The AME can comment on future medical treatment but AME's can no longer approve or deny medical treatment. So if your AME writes he does not recommend shoulder surgery it does not mean you cannot get it. Treatment requests are now subject to UR and IMR (if the claims adjuster does not approve the request). AME's can make decisions on if your condition(s) are work related.

Yes, I did get SDI, but didn't get much because I was a Federal Officer for 10 ten years prior to my current private sector position. Thanks for the advise. I will keep you updated..
 
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#6
My attorney filed for an expidited hearing in regards to my ttd pay. It is scheduled for Sept 23 but the defense attorney can't make so it was cancelled. The defense attorney did agree on paying me retroavtive ttd so yay for me.. The insurance accompany according to the defense attorney will send the check by mail today. I hope so. Now my AME should be finished by the end of this month..Still no authorizations as of yet for my surgery and epidurals.
 
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#7
Hey this is great news you are getting your back payment TTD! I am glad you asked your attorney to file for a hearing. Once you receive it check for accuracy on the amounts and dates (no I do not trust the IC as many IW's are underpaid).

You should have heard back from UR as long as your injury is not denied. It is accepted correct? UR has 5 business days to respond to your doctors requests and 14 days to respond if they need more info from your doctor. I recommend doing some leg work and ask your doctors office for copies of you last few reports AND the RFA forms and the fax or mail confirmation page for the requested treatment. The main reason why requests are ignored (other than the injury is denied or the doctor is not in the MPN) is the doctor did not use a RFA form.  Of your doctor used the correct for then I would send it to your attorney and ask for an expedited hearing. Please review the RFA closely as sometimes doctors request something in the PR-2 narrative and they do not list it on the RFA.

The AME no longer makes decisions for medical treatment. They can opine on it but it is your doctor who requests the surgery and your adjuster can approve it OR send to UR. If this AME states you do not need the surgery, he is not the deciding factor, but I would recommend getting another opinion and do not have any surgery without getting a few opinions first as this AME may be looking out for your best interest (unknown).
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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