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C and R, then need lumbar surgery -is private insurance strict?
#1
State of California.  48 years old.
My attorney met with the IC attorney for a status hearing on Aug.2 and he told me that things were moving along really well and the session was productive. He said the IC attorney is willing to do a C and R and things could be finalized if all goes well by end of December.

(I am not sure what my PD rating is as the Rater was not in attendace on Aug 2nd at the courthouse – but my WPI rating before any prior injuries were factored in was 45%)

Factored into the AME Drs final assessment for future medical care is that I may need Lumbar surgery. He did not specify which kind.  I understand that there is a scale that is used to equate the surgery to a cash price that is below what one might find outside of the work comp world.

I have cervical and thoracic issues as well but the bulk of the future medical seems to be dedicated to my lumbar issues which are:  2 mm disc bulge at L4-L5, 5 mm disc bulge at L5-S1. Moderate to severe foraminal encroachment on the left L5 nerve root, small annular fissue at L4-L5 and small annular fissure at L2-L2. 

I understand that by signing the C and R,  it could potentially be very damaging to me if I end up needing lumbar surgery down the road and I have not set aside that lump sum settlement for it. 

If I take the C a nd R and  I have private insurance, and somehow God forbid down the road, I re-injure the low back, either in a car accident, or something  that causes the disc to come out more, do private insurances consider that a new incident, therefore not a pre=existing condition?  

Right now I am getting  chiropractic care, pain meds, etc for my low back, all covered through my private insurance.  So I am curious if the need ever arose in 3 years or so for me to have lumbar back surgery, if they would put up a stink. I understand every insurance company is different but I am just trying to get a lay of the land.

The Utilization Review process and request for treatment are so incredibly tedious and unproductive, that to settle my case leaving the Future medical Open, is not something I want to do.  The bureaucracy involved in getting anything approve d is just too much to handle. Because nothing gets approved.

My attorney is very much wanting and pushing for the C and R and also doesn’t’ really get too involved in the “what if” questions.  So I am hoping someone out there may have some experience or know someone who settled for C and R, and ended up needing surgery and having it covered by their private insurance.

Thanks!
 
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#2
I never heard of any such scale. while spinal surgery may relate indirectly to rating it doesn't correlate to C&R $$.
every surgery, patient, and surgeon is different. the outcome and followup care vary greatly.

probably.
the liability and need for treatment is almost always related to the current triggering event rather then some pre-existing injury.
medicare however will not pickup treatment for comp injuries if the C&R is very proximate to your medicare coverage.
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 have seen injured workers close out their claims and immediately use their private insurance. This does not mean all insurance companies are doing this... but I recommend to check with your private insurance If you have Medicare that is a different story. I recommend talking to your attorney about this. He should know if his clients are having a problem with private insurance after a C&R.

As you are aware the current UR and IMR system is horrible to get treatment, especially if your doctor is not appealing the denials (very few are). I highly recommend to get out of this horrid system and get yourself a good doctor in private insurance who will provide you with a lot of physical therapy.

There is not a lot of money in the work comp system as far as reimbursement for how badely injured patients have become from what I have seen. If your injury is after 1/1/2013 and your employer will not take you back you will be eligible for additional money via voucher. In my opinion returning to work is a better deal than these vouchers. I hope you can return to your previous job.
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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