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NC - perm partial disability - multiple MDs to rate the part for different Dx
#1
Hi folks
I was injured 4 years ago, had to have extensive surgery on my leg/foot, reached MMI for structure & function (50% perm total disability per the orthopedic surgeon) and am in ongoing pain management indefinitely. I have residual nerve pain that was treated with a spinal stimulator (after trying everything else for a year). The stim is great, doesn't change the limited function but does help with the pain 75% of the time. I cant have it on when I drive, and sometimes I have to change the program to increase pain blocking. it's still better than opiates (brain fog). I do have to take oral meds (lyrica) to help- the stim and the lyrica work together to keep it so that i can focus to work. I returned to work and my employer has been great and I am thrilled to be back in the land of the living. I have an attorney since the start and she has been great. The adjuster (on the 3rd one now), the nurse case managers (5 so far) and their attorney (same one all along) are another story entirely. They're like the Moe Larry and Curly of their industry. We can't figure out if they are really clueless, playing clueless, or a bit of both.

So I have meds indefinitely, sporadic PT indefinitely, a permanently implanted device which needs maintenance over time. I have reached MMI with the orthopedic surgeon as the function (range, weight limit, etc) is fixed. 60% permanent disability of the leg.  I broke my heel on the other foot so i also have 5% disability of the foot. it didn't need as much as the other leg. Anyway, now that the pain dr. has my pain managed with the implant provided by the neurosurgeon, the adjuster wants the pain doctor to re-rate my worse leg. I'm not going to be discharged from the pain mgmt dr since its ongoing care.  My attorney says that when this happens, usually the rating is higher but it clouds the rating provided at MMI by the orthopedic surgeon. We suggested that if they want the pain dr to rate the leg, it would be in addition to the existing rating (and the end result cumulative). The adjuster and the nurse believe that the pain dr. can give a rating that that would replace the orthopedic surgeon rating.  The functional /anatomical permanent disability is distinct from the potential additional disability from pain management treatment.  Maybe there would be some restriction due to a spinal device (bending, lifting etc).

they offered a laughable  settlement, which I refused with advice from counsel and physicians (who estimated future costs) and at this point I am moving forward and they are responsible for lifetime medical. I dont anticipate any TTD, unless my wiring needs to be replaced. I plan to file form 26A, Form 18M, and get this show on the road.  I am told the nurse will keep calling every week (fine) and meds will continue to go through Timesys. Since I have monthly medical expenses, the 2 year time period after rating payment doesn't apply. The adjuster may or may not realize this- it is hard to tell. They tried to tell me to have my husband's health insurance pay for the meds instead of them for the duration. We had to say hello, it is a work related injury and not allowable /not covered as such. She said, and I quote - 'other people do it and it works'. Seriously, I can't make this stuff up. Sure some folks may get away with that, but that's um...fraud. talk about trying to shift risk!

Now to my questions-- I have 2 -- 1) what would you do about the request for the "re-rating"? It doesn't seem plausible that a pain med (anesthesiologist) would provide an overall rating that trumps the orthopedic surgeon. The nurse & co tried to get the orthopedic surgeon to give his opinion on the pain mgmt, and he told them very clearly- that isn't in my scope. i am pretty sure the pain med dr. is going to say the same thing, or agree to rate separately.  

Second question is what are potential negative consequences of putting the hammer down and making them move ahead with the form 26A and 18M? I have read that sometimes once the rating is paid, they start denying meds. My meds are very expensive (half my pay a month!) so I dont want to put myself in a position where I have to chase them, have out of pocket, threaten or take them to commission (again- yep, had to go twice already, because they were "confused" -- and of course they agree to terms on the steps before going in. that is what i mean by are they just clueless or is that part of the "game"). I work, I have a family, I finally feel better for now. I want to move forward but I also dont want to open up another can of worms with these jokers. I am fine filing form 18M and sit on form 26A if that makes a difference.  All of these scenarios I have been discussing with my attorney, but i thought asking this group could provide another perspective --  it's been a long game, need some fresh legs as they say in soccer! Thanks for any thoughts and sorry for any typos-- tried to catch em all!
 
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#2
I don't think you have grounds to refuse to see the pain doctor.
at some point the rating will be paid so whatever the consequences they can't be avoided only delayed.
you should make sure your atty will be willing to go back to court to fight for treatment after he gets paid.
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
I hadn't thought about that-- once the PPD is paid, the original agreement with the attorney has been met? Is the usual course to re-retain if benefits are denied? By having form 18M in place from all MDs, which states the treatment, if the adjuster suddenly starts denying treatment approved by NCIC via the form I would think filing a complaint/scheduling a hearing would be next step and then re-hire the attorney? Is it possible in those instances to require w comp to pay for all fees related to having to bring such an action? I don't want to have to pay out of pocket for representation for ongoing, indefinite treatment that has been clearly documented, approved, and is ongoing. I can see opportunity for them to play more games, since they tried delaying Rx refills and other tactics in the past couple of years. By games, I mean the adjuster will say oops, I forgot to renew your Rx in Timesys-- 'just pay it and we will reimburse you', when they know my pay rate and that it is half my month's pay to purchase the Rx - i.e. delays cause undue financial stress on my family- and they know that.

Thanks for the advice- I appreciate any feedback as I sort this out. Seems like I need to delay the 26A.
 
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#4
The representation as attorney of record remains until they are officially dismissed.
All atty fees for work comp are paid out of disability benefits available.
Discuss post award representation with your atty; don,t assume.
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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