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workers comp case denied
#1
Hello
I am seeking advice and opinions on my case.
I hurt my lower back in October 2013 at work ruptured one of my disc. I had to get surgery and settled my case in August 2014. Back then I was told I have 12 month after I signed the settlement to report any issues I may have with my back and it would be covered under the same claim.

I start to have issues again in March 2015 I reported it and was sent to the surgeon. The surgeon said he needs another MRI done to see what’s wrong. A few days later I get a call from the insurance company saying the claim was denied because I have a sitting job and there see no change of condition.
I had an MRI done a few days later and the surgeon said it’s the same disc and I need another surgery.
The surgeon filled out a form, saying I can go back to work till I await surgery with only one restriction not lifting more than 20lbs. My employer called me after I dropped off the paper and telling me I am not allowed to work till I get my surgery.

I was told my Employer wants to try to say since I have a sitting job my change of condition is due to my going to the gym and working out. I do work out. I was never told I cannot work out anymore.
My question is can I really lose this case because I work out? I am a bigger guy and I do lift weights but I never hurt myself or was hurting doing that.
Thank you
 
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#2
whether you have an aggravation from working out or it just a continuation of your prior injury or you've had a new work injury is a medical question and cannot be determined by you or your employer/carrier without supporting evidence.
you did not say what your surgeon thinks. what is his opinion as to the cause of your current condition? new injury or the october 2013 work event or something else?
medical opinion/evidence is what will decide 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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#3
(09-10-2015, 04:47 PM)1171 Wrote: whether you have an aggravation from working out or it just a continuation of your prior injury or you've had a new work injury is a medical question and cannot be determined by you or your employer/carrier without supporting evidence.
you did not say what your surgeon thinks. what is his opinion as to the cause of your current condition? new injury or the october 2013 work event or something else?
medical opinion/evidence is what will decide the claim.

"Reviewed MRI and it shows a sizable recurrent L5 s1 herniation" that's what the doc says in his last note.
But i do know he was talking to my employer after this and now he says he feel like i could have hurt myself at the gym.
 
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#4
if the tear wasn't there before your prior surgery, seems to be a strong case for a new injury and not the 2013 work incident. the employer/carrier maybe correct to want more evidence of their liability for this new round of treatment.
your health insurer should provide coverage for a denied comp 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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#5
Shy 
(09-10-2015, 06:47 PM)1171 Wrote: if the tear wasn't there before your prior surgery, seems to be a strong case for a new injury and not the 2013 work incident. the employer/carrier maybe correct to want more evidence of their liability for this new round of treatment.
your health insurer should provide coverage for a denied comp claim.

Sorry i don't fully understand what you mean the tear was not there before my prior surgery?
I try to explain it better. i had a herniated disc from a accident at work. A disectomy was done and now i have a new MRI showing the same disc the same location a recurrent herniation.  I had no accident like i had the first time it happen. i went back and reported it because i had on and off aches in my back especially when sitting too long.
I was released to full duty by my surgeon. I asked him will i have any limitations after the surgery, he said i can play football after it is done. in no way was i ever told this surgery will only last 11 month after i was released to full duty.
 
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#6
a herniation usually results from a tear in the disc. that herniation and tear was not present after the initial surgery/repair and likely occurred between the first surgery and now. therefore something other then the work injury of 10-2013 was involved.
an injury is an event. it is not a place or a body part. you can have multiple injuries to the same finger many times; each is a separate injury. the fact that its the same disc at a later time does not make it due to the same event as the earlier herniation.
that's why a detail history is important when assigning liability to workers comp.
just having one injury to your back at work doesn't make a former employer liable for everything that happens to your back from then on.

unless you can medically tie this second herniation to the original event at work it's going to difficult to make the employer pay for a new surgery.
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
(09-10-2015, 10:10 PM)1171 Wrote: a herniation usually results from a tear in the disc. that herniation and tear was not present after the initial surgery/repair and likely occurred between the first surgery and now. therefore something other then the work injury of 10-2013 was involved.
an injury is an event. it is not a place or a body part. you can have multiple injuries to the same finger many times; each is a separate injury. the fact that its the same disc at a later time does not make it due to the same event as the earlier herniation.
that's why a detail history is important when assigning liability to workers comp.
just having one injury to your back at work doesn't make a former employer liable for everything that happens to your back from then on.

unless you can medically tie this second herniation to the original event at work it's going to difficult to make the employer pay for a new surgery.

You said an injury is an event I can agree but only to the actual first injury/event at work. Yes that was an event I tell you when my disc popped I got almost whipped off my feet. But I did not had such an event when I went back to my employer reporting my aches I have now. It just started to bother me more and more especially when I was sitting too long at my desk at work.

I also disagree with the assumption that there was no tear after my surgery and comparing it with a finger being cut.
Ones the surgeon goes in and cuts a piece off the disc, it will always be a tear/damaged disc. A disc does not heal like a finger does. It will never grow together again in fact it will shrink/dry out over time and at one point in my life I probably will have to get it completely removed and the spine fused together. 

I also found an article on the spine health website which says the opposite of what you stated that something other then the work injury was involved:
Recurrent herniated discs are not thought to be directly related to a patient's activity, and probably have more to do with the fact that within some disc spaces there are multiple fragments of disc that can come out at a later date. Unfortunately, through a posterior microdiscectomy spine surgery approach, only about 5 to 7% of the disc space can be removed and most of the disc space cannot be visualized.

I am trying to figure out how the system works because I find it very unfair that I was told I would have 12 month after I sign the settlement to report any problems and it will be covered under the same claim. Just to find out that it isn't so. And now the insurance company blaming me for doing a very common and healthy activity for my problems. Especially when I was encouraged to do it by the surgeon and my employer to work out.
 
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#8
that is not how comp works.
there is not much more to explain.
I think you will have difficulty getting your logic accepted by the legal system and make the employer liable for more comp benefits. you should contact some work comp attys and see if you can find one that will take the case.
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
Can you write what state you are from because every state has different WC laws.

I recommend contacting an attorney. You can use your private insurance if this injury is denied.

Sometimes these discectomies are a temporary fix. 

What surgery is your doctor recommending now?
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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#10
(09-11-2015, 03:36 PM)California_Help Wrote: Can you write what state you are from because every state has different WC laws.

I recommend contacting an attorney. You can use your private insurance if this injury is denied.

Sometimes these discectomies are a temporary fix. 

What surgery is your doctor recommending now?

I am in SC. The doctor recommend another discetomy.
I do have a lawyer and he thinks i should have a good chance to win this case.
Only think what he worries is if the surgeon now will say that there is a chance i may got hurt at the gym
ones again i never said i got hurt again like having an injury/event. I just notice increase in pain after sitting too long at my desk.
 
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