Workers' Comp - Roadblocks to Proper Medical Treatment

It's been a ongoing battle with XYZ Mutual Insurance Company which included a Contested Case Hearing (CCH) last Friday, January 28 where the injured party, an office worker, is battling to get his regular life back. That is a life without excruciating pain.

He's been fighting for more than a year to be approved for back fusion surgery on three vertebrae, the only treatment option that will alleviate his debilitating back pain from an on-the-job injury that happened years ago.

It's been ten years since the first 3-level back surgery was done. The discectomy procedure, which was considered "minimally invasive" was developed to remove herniated disc material that protrudes from between vertebrae and presses against nerves. This excess material causes extreme back pain and often numbness to the legs, feet and even the toes.

The time frame is part of the problem with a Workers' Compensation Claim. Although the worker is "covered for life" on this injury, there are many obstacles that must be overcome to get the treatment one orthopedic surgeon says is necessary.

When the worker went back to the original orthopedic surgeon complaining of severe back pain, the doctor was required to reopen the original Workers' Compensation claim. This began the precertification process once again. Before more invasive treatments will be approved, all less invasive treatments must be tried and eliminated.

Part of the requirements for obtaining medical treatment from Workers' Comp is to have "Peer Review Doctors" to confirm or deny the treatment recommendations of the original doctor. So each time something new is prescribed, a host of paperwork is transmitted to approve or deny the original doctor's recommendations.

This causes a number of delays in approval for both general treatment and prescription medications while the paperwork is shuffled around, during which the worker continues to experience ongoing pain.

Workers’ compensation is a state-regulated insurance program that provides covered employees with income and medical benefits if they sustain a work-related injury or illness. Texas private employers can choose whether or not to provide workers’ compensation insurance coverage for their employees. In most cases, your employer is required to notify you whether or not they provide coverage.

Workers’ compensation pays your medical bills (for things they approve in advance) and replaces a portion of your lost wages. But what if you are working through the pain. You have a good job that you like and are making good money. There is no money to be awarded from the worker's claim for lost wages, only ongoing medical treatment.

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February 3, 2011 - Twelve months into the denials and whims that need to be met to give an injured worker necessary medical treatment.

Friday, January 28 Attended the Contested Case Hearing. That's where the Big Insurance Company brought in their attorney and by telephone called one of their Doctors as a witness. He testified there was no medical necessity of giving the worker the recommended surgery in his opinion, although admitting he had never seen actual x-rays nor had he ever examined the patient who was asking for surgery.

Copies of the evidence the opposing attorney was going to present at the hearing never got to the worker until the Monday after the hearing. They had been mailed by regular mail postmarked the day before the hearing. Oops. Sorry.

Immediately before getting ushered into the courtroom which looked just like the real thing with a Judge and recorded proceedings and swearing in of the parties, anyhow, we received a document from our Ombudsman with an appeal date sometime in February. We had yet to attend the hearing and they had already scheduled an appeal date.

I asked why, of course. The answer was "Should that be necessary".

Now we wait for the decision of the Hearing Officer which can take up to 15 days before we know the results of the hearing.

To be continued . . . . .