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Doctor lied on PR-2 form - CA
#1
I have an approved work comp claim and the work comp insurance co my employer had at the time of my date of injury is paying me (PD now, pending settlement - already had trial - now up to judge).

The issue I'm still having is with my private disability insurance through my former employer (they let me go while on leave). Disability has denied benefits for both STD and LTD since last summer. I am supposed to be supplemented to 2/3 of my salary but I am not getting anything and EDD denied me also.

I ordered my claim file and now I understand why. There is a report in my file that I was unaware of, and the report does not state the truth. Not only is the information totally false that is written, but the doctor who wrote it isn't even one of my treating physicians nor is she in the same field / specialty that is required for my injury.

I went over the notes and in doing so, noticed two things. 1. I have an email proving that what was said to me in our appt is not as the doctor stated because I emailed some questions after the visit (this email was omitted from the claim file but I have a copy of it from my medical file and the online hospital system). 2. The notes the doctor recorded in my file PRECEDED my appointment, so the office visit notes were documented and recorded on the system by time stamp, before I ever met this woman. Yet, she felt the need to make up things, lie about a few more things, and then by doing that special PR-2 form (Primary Treating Physician's Progress Report), single handedly cut off my benefits.

I have no idea what avenue to take to get someone's attention on this matter. I have appealed with disability (lost) I have appealed with the hospital (lost) I tried to find an ERISA attorney (didn't go so well-no real money in it, apparently) so does anyone have another suggestion on where I might get some help?

Similarly, upon reading the notes by my private insurance company and as outlined to their 'clinical review team' for recommendation regarding my last appeal, information was misrepresented to the point where I was made out to be, according to their opinion, lying about my injury and not taking my injury serious enough to seek treatment. I'm not even going to bore you with the details on that other than to say, I submitted a five page document outlining all my steps and provided the who what where and when as to being blocked from actually getting treatment, yet the report says there is no evidence to the contrary to their findings of 'lack of intent' on my part. I am out of appeals, as in no more allowed because I lost them all.

I have reached out to some other types of attorneys but not holding my breath since they are not specifically ERISA attorneys. Is there anything I can do to bring attention to this issue?
 
Reply
#2
(10-02-2016, 12:32 PM)BB019 Wrote: I have an approved work comp claim and the work comp insurance co my employer had at the time of my date of injury is paying me (PD now, pending settlement - already had trial - now up to judge).

The issue I'm still having is with my private disability insurance through my former employer (they let me go while on leave). Disability has denied benefits for both STD and LTD since last summer. I am supposed to be supplemented to 2/3 of my salary but I am not getting anything and EDD denied me also.

I ordered my claim file and now I understand why. There is a report in my file that I was unaware of, and the report does not state the truth. Not only is the information totally false that is written, but the doctor who wrote it isn't even one of my treating physicians nor is she in the same field / specialty that is required for my injury.

I went over the notes and in doing so, noticed two things. 1. I have an email proving that what was said to me in our appt is not as the doctor stated because I emailed some questions after the visit (this email was omitted from the claim file but I have a copy of it from my medical file and the online hospital system). 2. The notes the doctor recorded in my file PRECEDED my appointment, so the office visit notes were documented and recorded on the system by time stamp, before I ever met this woman. Yet, she felt the need to make up things, lie about a few more things, and then by doing that special PR-2 form (Primary Treating Physician's Progress Report), single handedly cut off my benefits.

I have no idea what avenue to take to get someone's attention on this matter. I have appealed with disability (lost) I have appealed with the hospital (lost) I tried to find an ERISA attorney (didn't go so well-no real money in it, apparently) so does anyone have another suggestion on where I might get some help?

Similarly, upon reading the notes by my private insurance company and as outlined to their 'clinical review team' for recommendation regarding my last appeal, information was misrepresented to the point where I was made out to be, according to their opinion, lying about my injury and not taking my injury serious enough to seek treatment. I'm not even going to bore you with the details on that other than to say, I submitted a five page document outlining all my steps and provided the who what where and when as to being blocked from actually getting treatment, yet the report says there is no evidence to the contrary to their findings of 'lack of intent' on my part. I am out of appeals, as in no more allowed because I lost them all.

I have reached out to some other types of attorneys but not holding my breath since they are not specifically ERISA attorneys. Is there anything I can do to bring attention to this issue?

Your LTD/STD will not know what a PR-2 or PTP in work comp is. They are two completely different insurance entities. I sent you a pm but The California State Department of Insurance is who I would contact about your LTD company. I am not sure anything will happen as these companies are notorious for denying claims and they are not looking out to be fair or in your best interest, they are looking out for their best interest. A ERISA attorney is the only one who can help with LTD/STD but you can reach out to CA State Department of Insurance to see if they will look into it.

I would recommend to do a little research on how they time stamp their reports just in case it is during record review, but something sounds off. Did you notice in your other records from that facility if the time stamp was after your exam? CA State Medical Board is supposed to oversee doctors and they have a complaint process.

Did you appeal the EDD denial if not I recommend it?

EDD, WC and STD/LTD all have different qualifications as what they deem disabled. I have seen patients receive 100% PD award in work comp, and they were denied disability payments with their LTD/LTD company. Those LTD companies can be horrible to deal with and in my opinion worse than work comp, your story is one I have read before unfortunately. Google LTD bad faith and whatever company you are dealing with name and you can read hundreds of horrible stories. They get away with it as it is difficult to get representation in an ERISA case as money paid to the attorney is very low. If you believe your LTD carrier acted in bad faith you can try to get an ERISA attorney or google the name of your LTD company bad faith insurance attorney and maybe you can find one who deals primarily with that company (I don't know if they can do anything if you are out of appeals). They do not have to be located near you as I have seen people hire ERISA attorney's on other side of the state.

Very sorry for what you have been throughSad
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.
 
Reply
#3
talk to the doctor that wrote the erroneous report and information.
If it,s corrected, it might be a faster way to undo the disability decisions that were based on it.
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.
 
Reply
#4
(10-02-2016, 07:02 PM)1171 Wrote: talk to the doctor that wrote the erroneous report and  information.
If it,s corrected, it might be a faster way to undo the disability decisions that were based on it.

The doctor knew exactly what she was doing. If you are interested in further details, I can PM them. But she knew perfectly well what she was doing. I tried to only give highlights of the situation so I didn't write a novel.  Rolleyes
 
Reply
#5
(10-02-2016, 05:02 PM)California_Help Wrote:
(10-02-2016, 12:32 PM)BB019 Wrote: I have an approved work comp claim and the work comp insurance co my employer had at the time of my date of injury is paying me (PD now, pending settlement - already had trial - now up to judge).

The issue I'm still having is with my private disability insurance through my former employer (they let me go while on leave). Disability has denied benefits for both STD and LTD since last summer. I am supposed to be supplemented to 2/3 of my salary but I am not getting anything and EDD denied me also.

I ordered my claim file and now I understand why. There is a report in my file that I was unaware of, and the report does not state the truth. Not only is the information totally false that is written, but the doctor who wrote it isn't even one of my treating physicians nor is she in the same field / specialty that is required for my injury.

I went over the notes and in doing so, noticed two things. 1. I have an email proving that what was said to me in our appt is not as the doctor stated because I emailed some questions after the visit (this email was omitted from the claim file but I have a copy of it from my medical file and the online hospital system). 2. The notes the doctor recorded in my file PRECEDED my appointment, so the office visit notes were documented and recorded on the system by time stamp, before I ever met this woman. Yet, she felt the need to make up things, lie about a few more things, and then by doing that special PR-2 form (Primary Treating Physician's Progress Report), single handedly cut off my benefits.

I have no idea what avenue to take to get someone's attention on this matter. I have appealed with disability (lost) I have appealed with the hospital (lost) I tried to find an ERISA attorney (didn't go so well-no real money in it, apparently) so does anyone have another suggestion on where I might get some help?

Similarly, upon reading the notes by my private insurance company and as outlined to their 'clinical review team' for recommendation regarding my last appeal, information was misrepresented to the point where I was made out to be, according to their opinion, lying about my injury and not taking my injury serious enough to seek treatment. I'm not even going to bore you with the details on that other than to say, I submitted a five page document outlining all my steps and provided the who what where and when as to being blocked from actually getting treatment, yet the report says there is no evidence to the contrary to their findings of 'lack of intent' on my part. I am out of appeals, as in no more allowed because I lost them all.

I have reached out to some other types of attorneys but not holding my breath since they are not specifically ERISA attorneys. Is there anything I can do to bring attention to this issue?

Your LTD/STD will not know what a PR-2 or PTP in work comp is. They are two completely different insurance entities. I sent you a pm but The California State Department of Insurance is who I would contact about your LTD company. I am not sure anything will happen as these companies are notorious for denying claims and they are not looking out to be fair or in your best interest, they are looking out for their best interest. A ERISA attorney is the only one who can help with LTD/STD but you can reach out to CA State Department of Insurance to see if they will look into it.

I would recommend to do a little research on how they time stamp their reports just in case it is during record review, but something sounds off. Did you notice in your other records from that facility if the time stamp was after your exam? CA State Medical Board is supposed to oversee doctors and they have a complaint process.

Did you appeal the EDD denial if not I recommend it?

EDD, WC and STD/LTD all have different qualifications as what they deem disabled. I have seen patients receive 100% PD award in work comp, and they were denied disability payments with their LTD/LTD company. Those LTD companies can be horrible to deal with and in my opinion worse than work comp, your story is one I have read before unfortunately. Google LTD bad faith and whatever company you are dealing with name and you can read hundreds of horrible stories. They get away with it as it is difficult to get representation in an ERISA case as money paid to the attorney is very low. If you believe your LTD carrier acted in bad faith you can try to get an ERISA attorney or google the name of your LTD company bad faith insurance attorney and maybe you can find one who deals primarily with that company (I don't know if they can do anything if you are out of appeals). They do not have to be located near you as I have seen people hire ERISA attorney's on other side of the state.

Very sorry for what you have been throughSad
 
Reply
#6
Sorry @California_help my responses didn't show...here is what I wrote that didn't post above...and also sorry to all that I don't know where the 'delete this post' button is.

You wrote:
Your LTD/STD will not know what a PR-2 or PTP in work comp is. They are two completely different insurance entities. I sent you a pm but The California State Department of Insurance is who I would contact about your LTD company. I am not sure anything will happen as these companies are notorious for denying claims and they are not looking out to be fair or in your best interest, they are looking out for their best interest. A ERISA attorney is the only one who can help with LTD/STD but you can reach out to CA State Department of Insurance to see if they will look into it.

My response:
Thank you! I will reach out to the CA State Department of Insurance. Also, I do know that the PR-2 form is for work comp, and I'm not even sure how the disability company got a copy, but yet it was in my claim file.

You wrote:
I would recommend to do a little research on how they time stamp their reports just in case it is during record review, but something sounds off. Did you notice in your other records from that facility if the time stamp was after your exam? CA State Medical Board is supposed to oversee doctors and they have a complaint process.

My response:
This is a time stamp on the actual doctor note and is part of my permanent medical record. I have reviewed a 4" thick file of medical records from the same medical group and they all have been consistent in how time stamps on notes to patient visits are recorded. The only way that note was recorded as having been made before my visit, is if it was made before my actual time in the office because you can't change that computer generated auto populated time stamp.

You wrote:
Did you appeal the EDD denial if not I recommend it?

My response:
No, but my attorney just told me at the trial that I should do that and also apply for SSDI - which I didn't think I was eligible for but since I've been out of work for over a year I guess now I do qualify.

You wrote:
EDD, WC and STD/LTD all have different qualifications as what they deem disabled. I have seen patients receive 100% PD award in work comp, and they were denied disability payments with their LTD/LTD company. Those LTD companies can be horrible to deal with and in my opinion worse than work comp, your story is one I have read before unfortunately. Google LTD bad faith and whatever company you are dealing with name and you can read hundreds of horrible stories. They get away with it as it is difficult to get representation in an ERISA case as money paid to the attorney is very low. If you believe your LTD carrier acted in bad faith you can try to get an ERISA attorney or google the name of your LTD company bad faith insurance attorney and maybe you can find one who deals primarily with that company (I don't know if they can do anything if you are out of appeals). They do not have to be located near you as I have seen people hire ERISA attorney's on other side of the state.

My response:
Very good suggestion to see if there is a particular firm or attorney that works with this particular insurance company. I have looked up before, and I absolutely know they deny valid claims for their own purposes. There are some class action law suits right now with other companies but I didn't see one for my particular company. I will do some more digging to see if there is a common theme as to who is taking on my ins co and try to get their attention. Thank you!

You wrote:
Very sorry for what you have been throughSad

My response:
Thank you very much. This board and the info received have been very valuable. It is hard when the injury is psyche, to try to understand everything. I think it is also hard when being represented by an attorney because suddenly, the avenues someone can use for information are closed off. When that happens the dependence on your attorney to help clarify things they are not part of, such as STD/LTD/EDD/SSDI etc., becomes greater. That is a no-win situation for some.

FYI - I have appealed to the STD/LTD company twice, and been denied twice. I have no appeals left however they didn't put a timeline in place for me to submit 'evidence' not yet provided. I am going to simply forward them my findings from my medical file, and also send them print outs of the current pending class action suits against the medical group. I think I'll just tell them like it is...I don't have anything to lose at this point. So I'll say that I have reached out to the law firm handling the class action and am trying to be part of it (which is true). I will highlight that including this information is in no way a threat to the disability insurance company but I do feel they should know in case they get brought into the mix, by association. I mean I have no idea if I will be able to join (no call back yet) but at least they will know I am not just accepting the decision. And I mean I have no idea if the disability ins co will be brought in to the mix and they may not but again, at least they will know that there is a strong possibility they acted on false information, and by me telling them, that would mean they knew about it and still chose to deny my claim. Well...worth a shot I guess!
 
Reply
#7
With the LTD company they rely on medical records and also forms they send to your doctor to fill out. If you have other records that were not supplied that would show your disability, I recommend doing it. It is very difficult for a person to fight a LTD denial without an attorney.

You are eligible for SSDI up to 5 years since last day worked. You can also apply for SSI (supplemental security income) at the same time you apply for SSDI at your social security office. You apply for State Disability with EDD and even though state disability may state you are past the deadline to apply they often times will give it anyway. You will need a treating doctor to fill out forms.

I wish you good luck on everything and if there is anything you need help with let me know.

I do wonder if going back to the doctor who wrote the incorrect report would help or request speaking to her supervisor and state what happened to you as a result. my only worry would be the facility may go into defense mode worrying about being sued.

You can request an addendum in writing when there are errors in reports. This may be a way out for the doctor and for you as well. For example a doctor wrote I had a neurologically disorder I was never diagnosed with in a report. I contacted the facility and asked how I would request an addendum. I wrote a short letter stating on page number the statement was incorrect as I have never been diagnosed or tested for this disorder and the doctor wrote it was a typo and attached her letter and mine to the incorrect report.
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.
 
Reply
#8
(10-03-2016, 07:35 PM)BB019 Wrote:
(10-02-2016, 07:02 PM)1171 Wrote: talk to the doctor that wrote the erroneous report and  information.
If it,s corrected, it might be a faster way to undo the disability decisions that were based on it.

The doctor knew exactly what she was doing. If you are interested in further details, I can PM them. But she knew perfectly well what she was doing. I tried to only give highlights of the situation so I didn't write a novel.  Rolleyes

you can file a complaint with the medical board or managed health care
http://www.dmhc.ca.gov/
http://www.mbc.ca.gov/
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.
 
Reply
#9
(10-03-2016, 08:51 PM)1171 Wrote:
(10-03-2016, 07:35 PM)BB019 Wrote:
(10-02-2016, 07:02 PM)1171 Wrote: talk to the doctor that wrote the erroneous report and  information.
If it,s corrected, it might be a faster way to undo the disability decisions that were based on it.

The doctor knew exactly what she was doing. If you are interested in further details, I can PM them. But she knew perfectly well what she was doing. I tried to only give highlights of the situation so I didn't write a novel.  Rolleyes

you can file a complaint with the medical board or managed health care
http://www.dmhc.ca.gov/
http://www.mbc.ca.gov/

I will do both. Thank you for the links!!
 
Reply
#10
(10-04-2016, 04:20 AM)BB019 Wrote:
(10-03-2016, 08:51 PM)1171 Wrote:
(10-03-2016, 07:35 PM)BB019 Wrote:
(10-02-2016, 07:02 PM)1171 Wrote: talk to the doctor that wrote the erroneous report and  information.
If it,s corrected, it might be a faster way to undo the disability decisions that were based on it.

The doctor knew exactly what she was doing. If you are interested in further details, I can PM them. But she knew perfectly well what she was doing. I tried to only give highlights of the situation so I didn't write a novel.  Rolleyes

you can file a complaint with the medical board or managed health care
http://www.dmhc.ca.gov/
http://www.mbc.ca.gov/

I will do both. Thank you for the links!!

Lying to deny benefits is fraud. Take your evidence to your local district atty or insurance commissioner
http://www.insurance.ca.gov/0300-fraud/0...and-forms/
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.
 
Reply
  


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