Workers' Comp - The Little Guy vs The Big Insurance Companies
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On The Job
Workers' comp. It conjures up images of big city lawyers and large insurance companies fighting for the little guy. Right? Not in this case.
The worker in this case is not typical of workers' compensation claimants who have a severe back injury. He holds a full time job despite agonizing back pain sustained working at a company years ago. The pain has grown exponentially over the past decade as the disks in his back continue to deteriorate from this on-the-job injury. But trying to get the surgery he needs has been an ongoing battle. Now the burden of proof is on him and he’s fighting for his future health.
In January 2010, when the pain level became intolerable, he returned to the original doctor who performed discectomy surgery in 2001, where he was instructed to reopen the original Workers' Compensation claim before treatment could begin.
Since then, it's been 12 months of ongoing agony, trying to get approved for additional surgery his doctor recommends to fix the problem. During this time, the Workers' Compensation guidelines have forced him to complete a battery of "less invasive" procedures including Psychological Testing, Neurological Testing, Physical Therapy and other criteria in hopes of being approved for lumbar fusion back surgery.
They actually required him to enroll in a "Work Hardening Program" designed to increase the worker's ability to return to work. Participating in this program eight hours per day would require him to quit his current job. Fortunately, Worker's Compensation authorized him to skip this requirement. Their "one size fits all" program didn't fit here.
What is an Ombudsman?
"An Ombudsman is an Office of Injured Employee Counsel employee who has a workers' compensation adjuster's license. The Ombudsman assists unrepresented injured employees when there is a problem or dispute in their workers' compensation claims that cannot be easily resolved."
Office of Injured Employee Counsel
Publication 448.4E Revised 08/08
Contested Case Hearing
Following months and months of postponement and delays, denials by so called "Peer Review Specialists" (Who are required only to be regular medical staff, not certified as to their specialization) and ineffective substitute treatments including referral to a Pain Management Specialist (aka Narcotics dispenser), we finally received notice that a Contested Case Hearing (CCH) was scheduled for the following week.
After meeting with our assigned ombudsman we've been led to believe we're certain to lose this case.
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- LABOR CODE CHAPTER 402. OPERATION AND ADMINISTRATION OF WORKERS\' COMPENSATION SYSTEM
Sec. 402.065. EMPLOYMENT OF COUNSEL. Notwithstanding Article 1.09-1, Insurance Code, or any other law, the commissioner may employ counsel to represent the division in any legal action the division is authorized to initiate.
Needle in a Haystack
Trying to find an attorney to represent us has been impossible due to the way the law is written to "protect" the victim from fraudulent counsel. No attorney will take our case as there is no money to be made from providing the injured party with the medical treatment he requires to live a normal life. Though we're willing to pay the attorneys, the law prohibits this.
Yep, that's what we've been told by a dozen attorneys that they are prohibited by law from taking our case and receiving compensation from us. Their monies are required to come from the claim. We are not asking for money, just medical treatment, and the salary compensation funds have long since dried up from the original claim.
TX Labor Code Chapter 4
(4) provide timely, appropriate, and high-quality medical care supporting restoration of the injured employee's physical condition and earning capacity;
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Current Bid: $8.99
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Liberty Mutual Insurance and the "ODG"
Liberty Mutual Insurance, staffed with an abundance of attorneys, assigned a lawyer to represent them at the CCH hearing, to refute the necessity of surgery. The best outcome would be that Liberty Mutual Insurance agrees to pay for three level back fusion surgery which the orthopedic doctor recommends, backed by CT Scans, X-rays, and MRI films.
But there's little chance of getting approved for the surgery which isn't listed in the "ODG" or Official Disability Guidelines and does not cover this type of surgery.
"Can't we present the X-rays as proof?" We asked our Ombudsman.
"Nope. The Judge will look at the "ODG" Matrix of approved surgeries and treatments, compare that with the Attorney's Exhibit 'A' and pronounce that the surgery doesn't fit into their guidelines." She advised us of this last Wednesday at our pre hearing meeting. She went on to tell us that this is very common.
Injured workers are being denied necessary medical care because it isn't on the "ODG". Is this what we can expect with the future of Health Care Reform?
The Victim's Rights
The victim in this case is the worker, my husband, who suffers daily debilitating pain that renders him unable to do most of the things an ordinary citizen of this country needs to do such as walking, sitting, standing and even sleeping which is fraught with agonizing pain.
We need help and there is no help to be found. Tomorrow is the contested case hearing, and we can only hope that justice will prevail.
Update October 2011
After we lost the Contested Case Hearing we went on to lose the appeal in District Court which was mostly a paper battle with no testimony required, just reams of paper copies.
On a positive note, after changing from the first skeezy Pain Center where we were sent to collect more pain medication, we located a wonderful doctor who is providing relief through epidural steroidal injections (ESIs). Although this is a bit frightening to a diabetic it's giving some much needed relief and some semblance of a normal life has returned. PTL
Update December 2011
The epidural steroid injections (ESIs) were working until the procedure on December 20. After a lot of walking at a business seminar around Thanksgiving the pain moved to the other leg and numbness appeared in the toes. With worker's compensation you have to wait for approval before any procedures are started. December 27 another MRI was approved by and he managed to make it through the 30 minute process of lying perfectly still on your back for the x ray.
December 29th we took the films to the original Orthopedic Surgeon who reviewed them and dictated into his steno machine that the patient's daily living situation is "intolerable". He turned us over to the nurse who is finally going to schedule surgery.
Now that we've exhausted all our appeals with worker's compensation the worker can finally apply for surgery through his current employer. It's just a matter of time now for all the claims forms to be processed and refuted and supported with more documentation.
Meanwhile, the worker continues to sleep sitting upright in a chair to avoid the shooting pains that extend down both legs if he lies down. Now we wait.
Other health related hubs by PegCole17
- Workers' Comp - Roadblocks to Proper Medical Treatment
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How do you make the decision on which hospital to choose? If you're lucky, you'll never have to go to the hospital. But there's a good chance you will eventually need to visit the hospital whether to see a friend, give birth, get medical treatment or
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Will, Thanks for your quick response to my rant. Your ideas are great and I'm in the process of contacting the TV news. I've tweeted and posted on FB. Now I'll keep on trying the public way. We've been quiet for long enough.
To Willstar -- this is NOT government run health care!!! I know, having spent most of my life in a country that does provide a sane system of single payer, patient driven (I.E. "government" health care).
To Peg: My heart goes out to you. Ever since I've arrived here I've heard similar stories from people battling some insurance provider or other, whether private-for-profit carriers or workmen's comp. Everyone who reads my work knows my feeling about the abysmal level of medical care in this country. Let me tell you a story: I had a damaged disk for quite some time, but the pain wasn't so bad to drive me to seek help. Then one winter day, I slipped on an ice covered step, fell down six concrete steps and did more injury. The pain was excruciating. I went to the local ER, was given shots for pain and transferred to the 'big city' hospital where I had an MRI at 1 in the morning. The next day I had surgery. And life went on. Do I say this to make you feel bad?
No! I say it more for comments like above. Canada does provide good care, no matter the propaganda you hear down here.
Which would you prefer?
And to your husband, I've lived with back pain and I know how debilitating it is. Keep fighting. Do all the stuff offered above, but don't for one minute call it a failure of 'government run' medical care. Workman's Comp is just one more carrier trying to weasel out of their committments.
God Bless both of you! Lynda
Hi Lynda - The sad part is that everyday people are being systematically neglected as a result of laws that are supposed to protect their rights. On top of that, Insurance Carriers and State Agencies are telling the Doctors what treatment they can and can't provide their patients.
The Insurance Carrier's Peer Review Doctor actually stated that he would deny our case if our Doctor did not call him back within fifteen minutes! Really. This is true. He has the power to say NO on a whim, thus destroying someone's life. This is power run astray. Someone who has never laid eyes on the patient can deny their claim.
We are in for a fight here and we know it.
Thank you so much for commenting and for your kind words. PS. Sorry for your back pain but I'm glad it got better.
I'm so sorry you and your hubby must got through this, My brother-in-law was in the very same circumstance, all through the seventies. He got tired of the rejections, went back to work and made it worse. Finally in 1980 he had his surgery and made them true believers. All those years of agony and food stamps, welfare and humiliation; even some family thought he was faking it and his friends. He is 100% disabled now. Keep your chin up girl and the best of luck to you both.
It might not be Government health care but they must be surely licenced by the government ! I would listen to Will !
GOOD LUCK from jandee
Hey Ralwus, Good to hear from you. Jim knows how your brother-in-law felt during all the rejections, denials and red tape. Meanwhile - the pain is ongoing. But he continues to hold onto a good job that he loves, where he is respected and valuable. Travel, which is part of the job has become an exercise in endurance as he stumbles through the walking and lifting required with it. We just want him to have the medical treatment he needs. But we're fighting the system.
Thank you for the encouragement and for sharing your story. Warm regards, Peg
Jandee my friend - Nice to see you again. You are right. The Workers' Compensation is a Federal Program that
"is a form of insurance that provides periodic payments in lieu of wages and medical care for employees who are injured in the course of employment, in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence."
Their primary goal is to return the worker to the workplace. But what about people who are already working?
Thanks for your comments. Kindly, Peg
That is a terrible situation. My bother has had 3 back surgeries and I know the pain he has suffered. I agree with WillStarr. Call everyone you can think of to get attention to the pathetic denial by workmans's comp.
Pamela99 - This is happening to other people on a routine basis. It's more than just a denial. They would probably approve his surgery if we wanted to settle for a 2-level back fusion, (That IS covered on the ODG) but our surgeon says it will probably NOT alleviate the pain. There's no guarantee the correct 2 disks will be fused of the 3 that are injured.
In addition, he would probably need to have a second surgery later - which means more pain, more time away from his current job, and more risk.
We have heard back from one TV Station who advised us to "Obtain an attorney". What? Didn't they understand, no attorney will take this case of the 12 we've spoken to. There is no money to pay them and they can't take our money by law.
Thanks for commenting and I wonder if the surgery helped your brother?
I'm not an attorney, although as I recall from school the Constitution of the United States of America protects citizens from situations such as this. Who among us hasn't heard the familiar phrase "You have the right to an attorney"?
If there are any legal people that can shed light on this, that would be helpful.
It's hard to imagine the State of Texas would pass a law allowing big corporations to send highly trained and specialized lawyers to a hearing and not allow the same for the injured party!
Oh my, I worked in administration for years. What I can tell you is this, they make a practice of turning down legitment claims and do so by a simple error in your paper work. They can turn you down because of an error in your paper work you filed. It doesn't mean the claim is not valid just that the filing was done wrong. I know I know sounds crazy, but it's the loop hole used to keep from paying.
Review your paperwork, look for any errors or omitions and refile!
Best Wishes and Much Success, :) Katie
RacerX - You would think that Workers' Comp would protect the rights of citizens, but as lmmartin said, they're just trying to weasel out of paying for medical treatment deemed necessary by a real doctor. I guess we only have a right to an attorney if we we've committed a crime.
Thanks for stopping in and for your comments.
Hi Katiem - We've been fighting the paperwork bureaucracy for months now which has delayed and forestalled progress on a regular basis. Our Dr.'s office will fax the requirements to the necessary recipient who will then "never get the fax". Yeah. At first we thought it was error on our end but they showed us proof that it wasn't. We've jumped through their hoops time and time again.
In this instance the paperwork is not the hold up. It it a dispute over proper diagnoses and medical need for surgery. Our Doctor says Jim needs surgery, they say they don't cover that surgery. Now the burden of proof is on us to medically prove this surgery is viable. We are not medical people nor is our surgeon available on a weeks notice to show up at a hearing. Their attorneys will provide medical evidence to refute and we will have no rebuttal. Then our only recourse is to take it to District Court, a long and drawn out process.
Thank you for your input and I wish we could remedy the neglect by filling in some paperwork. This whole thing reminds me of the movie "The Rainmaker". Deny, deny, deny. We must be "stupid, stupid, stupid".
Voted Useful. Great useful hub. Thanks for sharing. My old man has still never received payment. He worked at Pizza Hut and a security box, which was metal, fell on his back! Didn't get a penny.
AskAshlie3433 - So sorry that happened to your old man. I do hope they provided adequate medical treatment at the very least. That's all we really want - the proper surgery to fix his condition and relieve the pain. Thanks so much for sharing your experience with this.
The loss of mobility and independence is usually depressing and the idea of making such a choice is heart wrenching.
Hi Manuel,
There is no choice for Jim, although you're right about the depressing part. The root cause of his pain is the original damage to his L3-L4-L5 disks. All 3 levels were surgically repaired in 2001 after MUCH red tape and months of "less invasive" ineffective treatments and denials. He is supposed to be covered for life through this claim, on which they are denying additional surgery because it doesn't fit into their "guidelines".
Thanks for stopping by and for your kind words.
I pray that your husband was successful with his law suit. The big insurance companies such as Liberty Mutual and Standard Insruance have acquired large sums of money through workman's compensation insurance from companies and individuals. However, when it comes time to follow through I give them a failing grade. The entire system needs to be overhauled.
Hi CeeJ, Thank you so much for your well wishes on Jim's success. It was really just a hearing where we were trying to get the state of TX to overturn Liberty Mutual's decision to deny surgery. We lost. Now we're appealing the hearing results in District Court. There is no trial or anything, just paperwork being shuffled around. We're still waiting for those results.
You are so right about Liberty Mutual and the insurance companies. They are protecting the employers and their shareholders, not the injured worker. We were amazed to find so many complaints against them on line in regard to denied and mishandled claims. The system does need a good overhaul.
Thank you for stopping by and for your prayers. May God bless you for your kindness.
Loss of mobility and independence and tend to be sad thinking of doing a select heart wrenching.
Hello topwords, Thank you so much for your heart felt comments. Nice to meet you here.
Oh Sista,
I wanted to get an overview of what was going on. I have an aching heart for you and your dear husband.
I am convinced this is a system embroiled in toxic and arbitrary guidelines, run by people who are encouraged to forget the 'golden rule' and where the correct and appropriate medical intervention is not respected/ even in the mix for consideration. It is a system that expects ready submission by weary people. It preys on those who are hurt and vulnerable, because of the very work they have done.
Please keep close to your husband's side. He needs you.
Absolutely DITTO to the ever-wise Will Starr. A very tiny nun (with a very big mouth) got through to a State Senator on my behalf (after years) so I could finally have some closure (very different issue, but I had long given up). Please try not to give up that hope. 'Someone/ something' will happen, work every angle you can and keep us in your heart for support.
I am sending you every positive thought I have for a more peaceful and comforting new year. Love, Maria
Dear sweet Maria,
Yes, toxic and arbitrary "guidelines"; you would understand completely about fighting the system for things that should be automatic. However, as we know, the worker's compensation insurance groups that employers select are in it to protect their customer, the employer, certainly not the employee who has been injured.
The insurance companies serve primarily to prevent employees from suing their employers for injuries sustained on the job. With that bureaucracy comes loopholes that allow the insurance companies to slither off into their muddy "guidelines" which are really "Bibles" that dictate what injured parties can expect for medical treatment. Anyhow, sorry for this long rant after your lovely and considerate message.
I should post an update on our current situation since things have deteriorated since the last entry. Right now, the issue is too close to give my words the perspective they need.
Thank you for the positive thoughts and we are praying for relief to come through the latest MRI results taken this month, December 2011, that he will meet the criteria for treatment now.
Lots of love to you and warm thoughts from your sista, Peg
Peg, this is such a sad story and I hope your husband finds comfort and peace from his pain. I have been a victim as well. My case was denied. I worked at a Pizza Hut and their security tower for their camera system fell off the wall and hit me on the spine. Ever since, I have been in terrible pain. I went to the emergency room and they gave me 3 days off. Everyone knows that the magic number is 4, days that is. 4 days or more and you can collect income. I went to a follow up and learned I had fractures through a MRI. That doctor gave me 2 months off work. I turned that excuse in and I was still denied. It triggered a chain of reactions. When I went back to work, the kitchen was completely changed. 2 days later, I was fired. Their reason was because I was eating pizza on the clock, something that everyone does. Brickstreet Insurance is a joke. I really hate hearing this story cause I know he is more then deserving. Hopefully you will be compensated for everything one day. I surely hope.
Hello Thelyricwriter. It's nice to see you here today and I want to thank you for explaining your situation with this sort of insurance treatment. You would think reputable companies would stand behind their sense of integrity and take care of wrongs like this.
Three days. I didn't know the magic number was three days. Interesting how companies find reason to "let you go" that never were enforced before your injury.
I am overdue for a major update on this situation that will turn into a hub in itself, so I'll just let you know that things are slowly getting better now that we've been through the system. There is a light at the end of the tunnel, still a work in progress.
Thanks for your great story and I wish you all the best in your continuing recovery.
Peg
I can relate. I have an old workes comp injury (knee surgery) that has been causing similar problems. Write all of the letters you want. Meanwhile, ask around and find a shyster lawyer of your own.
You live in Texas, so it should not be too hard to find one!
Back pain is the worse. I have some pretty good injuries myself. This old retired doctor told me to wet a hand towel, wrap a heating pad around my body with an ace bandage and leave it on all day (extension cord). I did it for several days, before it started working, but it worked.
Hello there WD,
On January 19th Jim underwent three level spinal fusion surgery to repair the three disks that were damaged from the original injury in 1999. He is in the process of recovery at the moment, on medical leave from his present employer.
This is no thanks to the Worker's Compensation folks or the responsible employer's insurance company who won a decision against treatment in the related court case. Not even the shyster lawyers would take this case since there was no money to be paid out, only medical treatment sought. (Money talks)
I sympathize with your knee pain and hope you wil eventually find relief. For my husband, the recovery is ongoing. He is eager to return to his job and thankful that we got the final kiss off by Worker's Compensation so that we could finally get treatment for this injury after two agonizing years.
Thanks so much for your insightful comments.
Hello Peg, first things first. Those *(*&^%&^!#@$ b_st_rds!!!
Ok, deep breath, Your hurting husband has been through hell and back. My hat is off to both of you. To you for managing to stay calm, cool and collected in the face of grievous, injustice, neglect and abuse. And on top of that being there for Jim throughout this long drawn out ordeal. And Jim, my heart goes out to you dude. You deserve so much more after all your years of working in pain.
This is an excellent article Peg. I'm surprised it hasn't won some kind of special accolade for investigative journalism. Yes it is your true story, but it's written very professionally. This is a tough, complex topic to get a handle on, so multi-layered with all the different scenerios and players involved. You've given a perfect example of what is wrong with the system. It's too big. Everyone is out for their own interests and forgetting about the injured party. It's so disheartening. I don't know where you get your courage and your strength from Peg, (both of you) but it is admirable. The photo of Jim lifting the van says it all. You guys rock!
Snakeslane, you are such a good friend to say all this. I can always count on you for an uplifting message. Oh, I am nowhere near calm, cool and collected. I wish I could tell you differently. This has affected our lives so deeply and dramatically; nothing is as it was. The current health problems that Jim is now suffering all relate back to this long neglected medical treatment, which took him to the point of near unconsciousness on pain medications that were dosed out. All this so they could avoid paying for this necessary surgery. It is shameful and wrong.
On a happier note, thanks for your vote of confidence on the writing of this article. It is a true story and a sad representation of how worker compensation and our legal system fail to protect the working people of this country.
About the van picture, you know that is a prop at Universal Studios, right? hahaha. He couldn't really lift a van before his injury. I love the name of the company painted on the truck, "Lacks Security." LOL
Thanks again, Snakeslane, for your insightful and compassionate comment. I am blessed with friends like you. Will pass along your sweet comments to Jim as well!
WillStarr Level 8 Commenter 16 months ago
Contact your representatives and ask for help. If that fails, contact your news outlets, radio, TV, and print.
Contact your governor's office.
Write a letter to the editor. Ask them if this is an example of government run health care. Ask them if this is what we can expect under Obamacare?
Organize a protest outside the Workman Comp's office building and inform the media of when, where, and why.
Contact your federal representative and Senators. The pressure they can apply is amazing.
Publicity is your best friend. Make good use of it.